emergent management of acute ischemic stroke pdf version

7/27/2019 Emergent Management of Acute Ischemic Stroke PDF Version

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EmergentEmergent

oo

Acute IschAcute Isch

Michael J. SMichael J. S

Dept. of NeurologDept. of NeurologLoyola UniversitLoyola Universit

anagementanagement

ff

micmic StrokeStroke

hneck, MDhneck, MD

& Neurosurgery& NeurosurgeryMedical CenterMedical Center


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Stroke IncidencStroke Incidencin the Uniin the Uni

IncidenceIncidence11

795000 strokes/year in US (ne795000 strokes/year in US (ne

300,00 TIA/year in the US300,00 TIA/year in the US1 stroke every 45 seconds1 stroke every 45 seconds

PrevalencePrevalence11

4.7 million cases4.7 million cases

2million stroke survivors2million stroke survivors

Estimated direct and indirect cosEstimated direct and indirect cos Quoted cost per person ~$50,0Quoted cost per person ~$50,0

Incidence differs among ethnic pIncidence differs among ethnic pRisk increases strongly with ageRisk increases strongly with age

Lloya Jones et al Heart Disease and Stroke Stat

and Prevalenceand Prevalenceed Statesed States

or recurrent)or recurrent)

s exceeds $7 billion/years exceeds $7 billion/year0 per year0 per year

pulations, gender, and geographypulations, gender, and geography

istics 2010 Update


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AssesAssesof Acutof Acut

Theobold ChartraNationalLibrary of

smentsmentStrokeStroke

, 19th CenturyMedicine


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Goals of thGoals of th

Stablilize patient/reversStablilize patient/revers

thromboluyis when apprthromboluyis when appr

Prevent peristroke comPrevent peristroke com

, pneumon a, cere, pneumon a, cereDetermine location of sDetermine location of s

Define mechanism of sDefine mechanism of s

Secondary prevention (Secondary prevention (

e Worke Work--UpUp

e strokee stroke

opriateopriate

plicationsplications

a e emaa e emarokeroke

rokeroke

prevent recurrence)prevent recurrence)


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Stroke EvaluatiStroke Evaluati

Potential ThrombPotential ThrombNINDS RecoNINDS Reco

Time IntervalTime Interval

Door to DoorDoor to Door

Access to neurological eAccess to neurological e

Door to CT completionDoor to CT completion

Door to CT interpretationDoor to CT interpretationDoor to treatmentDoor to treatment

Door to monitored bedDoor to monitored bed

on Targets Foron Targets For

lysis Candidateslysis Candidatesmendationmendation

Time TargetTime Target

10 minutes10 minutes

pertisepertise 15 minutes15 minutes

25 minutes25 minutes

45 minutes45 minutes60 minutes60 minutes

3 hours3 hours


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Time ITime IEffects of tEffects of t

8

7

6

5

4

ioforFavorable

meat3Mo

60 70 80 90 100 110

3

2

1

0

Benefit for rt-PA

No benefit for rt-PA

Minutes frto Start

OddsRat

Out

c

Brain:Brain:A vs TimeA vs Time

120 130 140 150 160 170 180

m Stroke Onsetof Treatment


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NIH StroNIH Stro(see AHA website(see AHA website

ConsciousnessConsciousness 00--33

CommandsCommands 00--22Visual fieldsVisual fields 00--33

Arm motor (R)Arm motor (R) 00--44

Arm motor (L)Arm motor (L) 00--44Limb ataxiaLimb ataxia 00--22

LanguageLanguage 00--33

NeglectNeglect 00--22

ke Scaleke Scaleor training modules)or training modules)

OrientationOrientation 00--22

Gaze limitsGaze limits 00--22

Facial paresisFacial paresis 00--33

--

Leg motor (L)Leg motor (L) 00--44

DysarthriaDysarthria 00--22

Sensory deficitsSensory deficits 00--22


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Transient ische

1.1. Neuroimaging evaluation withinNeuroimaging evaluation within

Patients with suspected TIA should

transient episode of neurofocal brain, spinal cord, or

without acute infarction.

MRI, including DWI, is preferrMRI, including DWI, is preferr If MRI is not available, perforIf MRI is not available, perfor

2.2. Noninvasive imaging of the cerviNoninvasive imaging of the cervi

3.3. Noninvasive testing of the intracrNoninvasive testing of the intracrpresence of intracranial stenosispresence of intracranial stenosis

4.4. Evaluation as soon as possibleEvaluation as soon as possible

Easton JD, et al. Stroke. 2009;40(6):2276-2293.

ic attack (TIA):

4 hours of symptom onset4 hours of symptom onset

rapidly undergo:

logical dysfunction caused byretinal ischemia,

ddCTCT

cocephalic vesselscocephalic vessels

anial vasculature to exclude theanial vasculature to exclude the

fter an event.fter an event.


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ShortShort--Term PTerm P

EmergencyEmergencyDiagnoDiagno

Outco

20.0%

25.0%

30.0%

10.5%12.

0.0%

5.0%

10.0%

15.0%

Stroke RecuTI

Within48 hr

Within90 days

5.3%

Johnston SC, et al. JAMA. 2000;284:2901-2906.

rognosis afterrognosis after

DepartmentDepartmentis of TIAis of TIAe Events

7%

2.6% 2.6%

rent CV event Death


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ABCDABCDSymptomSymptom

AAgege 60 years60 years 11

BBlood pressurelood pressure 140/90 mm Hg140/90 mm Hg 11

CClinical features [of TIA]linical features [of TIA] 22

ww

DDuration [of TIA]uration [of TIA] 2211

DiDiabetesabetes 11

Maximum score is 7. Score 6 or 7 = high risk.

Johnston SC, et al. Lancet. 2007;369:283-292.

ScoreScoreScoreScore

pointpoint

pointpoint

pointspoints for unilateral weaknessfor unilateral weakness or speec mpa rmen w ouor speec mpa rmen w ou

aknessakness

pointspoints forfor 60 minutes60 minutespointpoint for 10for 10--59 minutes59 minutes

pointpoint


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Stroke Risk bStroke Risk b

2 days7 days

30 days

90 days

25

20

15

erisk(%)

Johnston SC, et al. Lancet. 2007;369:283-292.

10

5

0

Stro

AB

0 1 2 3

ABCDABCD22

ScoreScore

D2 score

4 5 6 7


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Limits of theLimits of theProspective study of 117 patientsProspective study of 117 patients

26 classified as high risk26 classified as high risk

(stroke or death within 90 d).(stroke or death within 90 d).

Frequency of high risk increasFrequency of high risk increas

Of those who had an MRI 15/61 (Of those who had an MRI 15/61 (

patients in the 0patients in the 0--4 categories4 categoriesfor patients with scorefor patients with score

for patients with scorefor patients with score

p value of trend= 0.24p value of trend= 0.24

Cucchiara B Stroke 20006Cucchiara B Stroke 20006

ABCD ScoreABCD Score

ed with ABCD scoreed with ABCD score

5%) had positive DWI lesions.5%) had positive DWI lesions.

--

aving positive lesions.aving positive lesions.of 5: 13%of 5: 13%

of 6: 60%of 6: 60%


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Limits of the ALimits of the AStudy in Calgary, Alberta,Study in Calgary, Alberta,

69 patients with TIA and 569 patients with TIA and 5Risk of new stroke at 90 dRisk of new stroke at 90 d

32.6%with DWI and ves32.6%with DWI and ves

10.8% with DWI and no10.8% with DWI and no 4.3% with no positive D4.3% with no positive D

Coutts SB et al Ann Neurol 2005Coutts SB et al Ann Neurol 2005

BCD Score (2)BCD Score (2)anadaanada

patients with minor stroke.patients with minor stroke.ysys

el occlusionel occlusion

occlusionocclusionI lesionsI lesions


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AdvaAdvain Radiologiin Radiologi

If there is no knowlIf there is no knowlunderstanding;understanding;

knowledge.knowledge.

cescesDiagnosisDiagnosis

dge there is nodge there is no

Pirkei Avot Chapter 3Pirkei Avot Chapter 3


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1. Early changes with loss of s1. Early changes with loss of s lci and edema on the right sidelci and edema on the right side


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LLeft MCA Str

T2 weighted image ofT2 weighted image of

ke by MRI

left cortical infarctleft cortical infarct


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Diffusion & PerfDiffusion & Perf

MR imMR im

Allows for early identifiAllows for early identifichanges.changes.

Can show tissue at risk fCan show tissue at risk f

Measures early changesMeasures early changeschanges in water contenchanges in water conten

Becoming more widespBecoming more widesp Immediate CT still mainImmediate CT still main

sion Weightedsion Weighted

agingaging

cation of ischemiccation of ischemic

r infarctionr infarction

in blood flow andin blood flow and

ead but overall utility?ead but overall utility?tay of diagnosistay of diagnosis


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Evolution of infarct size oEvolution of infarct size oB re resents the relatedB re resents the related

er time by DWI (A,C, D)er time by DWI (A,C, D)rfusion ima e.rfusion ima e.


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From the UCLA group: The advantFrom the UCLA group: The advantages of MRA and DWI in diagnosis of strokeages of MRA and DWI in diagnosis of stroke


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CT PeCT Pe

A large area of CT perfusion deficit

fusionfusion

as a result of new right cerebral ischemi


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ManaMana ementement


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NINDS rtNINDS rt--PA AcPA Ac30% more likely to have little30% more likely to have little

NNT: 1 stroke preventedNNT: 1 stroke prevented(a very strong ratio for d(a very strong ratio for d

Symptomatic ICH = 6.4% vs.Symptomatic ICH = 6.4% vs.

esp e s, no overa nesp e s, no overa nandandoverall benefit factoroverall benefit factorcomplications!complications!

NEJM 1995; 333: 1581NEJM 1995; 333: 1581--77

te Stroke Studyte Stroke Studyor no deficit at 90 daysor no deficit at 90 days

or every 8 treatedor every 8 treatedug therapies)ug therapies)

0.6% controls0.6% controls

rease n mor a y w rrease n mor a y w r --d in hemorrhagicd in hemorrhagic


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TPA in CliniTPA in CliniOnly 3%Only 3%--4% of stroke patients receiv4% of stroke patients receiv mostly due to time delaysmostly due to time delays

In real world, results acheivable thatIn real world, results acheivable that Rate of ICH: 4%Rate of ICH: 4%--6%6%

Risk of ICH increases with protocol viRisk of ICH increases with protocol vi Time >3 hoursTime >3 hours

Poor blood pressure controlPoor blood pressure control Use of prohibited medsUse of prohibited meds

Wrong doseWrong dose0.9 mg/kg0.9 mg/kg

Maximum dose: 90 mgMaximum dose: 90 mg

Elevated blood sugar also increasesElevated blood sugar also increasesCleveland experience shows that staCleveland experience shows that staoutcome.outcome.

Adams HP, et al. ASA Stroke Council. Stroke. 2003;34:105

cal Practicecal PracticetPAtPA

re similar to NINDS trialre similar to NINDS trial

olationsolations

riskrisking with the protocol improvesing with the protocol improves

-1083.


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Overall BeneOverall Beneof IV tPAof IV tPABenefit: neurologically normal at 3 moBenefit: neurologically normal at 3 mo

55% relative increase55% relative increase 12% absolute increase12% absolute increase

Very robust effect:Very robust effect:

NNT for neurologically normal: 8NNT for neurologically normal: 8

NNT for improvement on mRS: 3.1NNT for improvement on mRS: 3.1Risk of symptomatic ICH was 6.4%Risk of symptomatic ICH was 6.4%

The overall benefitsThe overall benefits includeincludethe ICHsthe ICHs

Risk of ICH can be reduced by closelyRisk of ICH can be reduced by closely

mRS, modified Rankin scale.NINDS rt-PA Stroke Study Group. N Engl J Med. 199

Adams HP Jr, et al. Stroke. 2003;34:1056-1083.Saver JL. Arch Neurol. 2004;61:1066-1070.

its and Risksits and Risksor Strokeor Strokethsths

following the tPA protocolfollowing the tPA protocol

;333:1581-1587.


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TPA 3TPA 3 --N=821: 418 to the alteplase gN=821: 418 to the alteplase ggroup.group.

Median time for the adminiMedian time for the adminihours 59 minutes.hours 59 minutes.

0.9 mg per kilogram of bod0.9 mg per kilogram of bod

dichotomized as a favorable odichotomized as a favorable o6 on mRS scale)6 on mRS scale)

The secondary end pointThe secondary end pointof four neurologic and disaof four neurologic and disa

Safety end points includedSafety end points includedintracranial hemorrhage, aintracranial hemorrhage, aevents.events.

ECASS III NEJM September 2008ECASS III NEJM September 2008

.5 hours.5 hoursroup and 403 to the placeboroup and 403 to the placebo

tration of alteplase was 3tration of alteplase was 3

weight or placebo.weight or placebo.

utcome (a score of 0 or 1 vs 2utcome (a score of 0 or 1 vs 2--

as a global outcome analysisas a global outcome analysisility scores combined.ility scores combined.

death, symptomaticdeath, symptomaticd other serious adversed other serious adverse


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TPA 3TPA 3--44Eligibility criteria same as 0Eligibility criteria same as 0--3 h3 hadditional exclusions:additional exclusions:

patients older than 80 yearspatients older than 80 years all of those taking oral anticall of those taking oral antic

international normalized ratiinternational normalized rati

those with a baseline Nationthose with a baseline NationScale score > 25Scale score > 25

those withthose with bothbotha history ofa history of

ECASS IIIECASS III

.5 hours.5 hoursour window plus the followingour window plus the following

agulantsagulants evenevenwith anwith an[INR] of 1.7[INR] of 1.7

al Institutes of Health Strokeal Institutes of Health Stroke

troke and diabetestroke and diabetes

EJM September 2008EJM September 2008


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NumberNumber--neededneeded--toto--

Benefit veBenefit ve In how many patients do we have to uIn how many patients do we have to u

(or harm) one patient?(or harm) one patient?

Benefit defined as favorableat 90 days criteria)

Harm defined as symptomati

11--3 hours (3 hours (

BenefitBenefit(NNTB)(NNTB)

1313(8)(8)

HarmHarm(NNTH)(NNTH)

5.5.(17(17

Benefit/Harm RatioBenefit/Harm Ratio 2.2.

1. NINDS rt-PA Stroke Study Group. N Engl J Med. 1995;3

2. Hacke W, et al. N Engl J Med. 2008;359:1317-1329.

Valu

reat (NNT) analysisreat (NNT) analysis

sus Harmsus Harmse tPA in order to benefitse tPA in order to benefit

utcome (0-1 on modified Rankin scale

ICH

Per 100 PatientsPer 100 PatientsNINDS)NINDS)11 33--4.5 hours (ECASS 3)4.5 hours (ECASS 3)22

7.27.2(14)(14)

))4.44.4(23)(23)

1.61.6

3:1581-1587.

s calculated from data in indicated references


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Hemorrhagic transformatiHemorrhagic transformati n of an ischemic stroken of an ischemic stroke


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ThromThrom

OtherOtherIV and IA (DRIP and SHIP)IV and IA (DRIP and SHIP)

IV (2/3)IV (2/3) -- 0.6 mg/kg [15% bolu0.6 mg/kg [15% bolu

IA (1/3)IA (1/3) -- 0.3 mg/kg0.3 mg/kg [2[22299

IV GPIIb/IIIa receptor antagoniIV GPIIb/IIIa receptor antagoni

Mechanical & pharmacologic tMechanical & pharmacologic t

Snares, baskets, aspiration deSnares, baskets, aspiration de

olysis:olysis:

ptionsptions

]]

g distal to clot;g distal to clot;g intrag intra--clotclotg r 2 rs; 22 mg maxg r 2 rs; 22 mg max

ts + IA thrombolysists + IA thrombolysis

rombolysisrombolysis

ices, balloonsices, balloons


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PROACPROAC

ProurokinaseProurokinase

Proximal MCA occlusionsProximal MCA occlusions6 hour window6 hour window

recanalization 66% vs. 18%recanalization 66% vs. 18%

mRS 0,1,or 2 significantlymRS 0,1,or 2 significantly 58% more likely to have58% more likely to have

Despite this FDA did not aDespite this FDA did not a

Furlan A et al Jama 1999Furlan A et al Jama 1999

(I and II)(I and II)

controlscontrols

reater than control !reater than control !no clinical deficitno clinical deficit

proveprove


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PROs aPROs a

of IA Thof IA ThSignificant improvement for majSignificant improvement for maj

(MCA and basilar territory)(MCA and basilar territory)Window may be extended beyonWindow may be extended beyon

6 (maybe 8) hours for MCA st6 (maybe 8) hours for MCA st

Downside is need for a very specDownside is need for a very specinterventional capabilities and tiinterventional capabilities and ti

d CONsd CONs

ombolysisombolysisr strokesr strokes

3 hours available for iv therapy3 hours available for iv therapy

rokes; longer for basilar strokesrokes; longer for basilar strokes

alized stroke team with neuroalized stroke team with neuro--e to assemble that teame to assemble that team


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Merci RetriMerci Retri ver Devicever Device


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MercMerc114 patients.114 patients.

Prospective nonProspective non--randrandLarge vessel (ICA, MCLarge vessel (ICA, MC

Placebo arm of PROACPlacebo arm of PROAC27 percent mortality27 percent mortality

TrialTrial

mized singlemized single--arm studyarm study, VB, BA) strokes, VB, BA) strokes

--II:II:


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MERCI 1+2 PrMERCI 1+2 PrInclusion criteria:Inclusion criteria:

Time window 3Time window 3--8 hours8 hours

Includes also 0Includes also 0--3 hours i3 hours i NIHSS>9NIHSS>9

Occlusion of ICA, M1, BA, VOcclusion of ICA, M1, BA, V

Primary Endpoints:Primary Endpoints: Successful revascularizatioSuccessful revascularizatio

Major device related compliMajor device related compli

Secondary Endpoints:Secondary Endpoints:

Neuro. Status at 30 and 90 dNeuro. Status at 30 and 90 d

Major adverse events at 30Major adverse events at 30

tocol Overviewtocol Overview

patient not TPA candidatepatient not TPA candidate

in all treatable vesselsin all treatable vessels

ationsations

ays (NIHSS and mRS)ays (NIHSS and mRS)

ays (death, new stroke, MI)ays (death, new stroke, MI)


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Merci TriMerci Tri47 percent event47 percent event--free recanalfree recanalVersus 18% in PROACTVersus 18% in PROACT--IIII

38 percent mortality38 percent mortalityVersus 27% in PROACTVersus 27% in PROACT--IIII

Difference attributed toDifference attributed topa en spa en s

Of 61 patients with recanaOf 61 patients with recanaComplications:Complications:Device related adverse evDevice related adverse ev

8 percent sx ICH8 percent sx ICH2% in control group2% in control group

FDA approval for this deviceFDA approval for this device

IDE exemption!IDE exemption!

l Resultsl Resultsization.ization.

placeboplacebohigher acuity in Merci Trialhigher acuity in Merci Trial

ization: 25% death in 90 daysization: 25% death in 90 days

nts 3.5%nts 3.5%

provided under a humanitarianprovided under a humanitarian

O tO t S t tiS t ti B liB li


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RecanalizationRecanalizationOutcomeOutcome(mRS 2)(mRS 2)

RxRx ContCont RxRx ContCont

PROACTPROACT--IIIIN=180N=180

66%66% 18%18% 40%40% 25%25%

IMSIMS--IIN=80N=80

56%56% .. 43%43% ..

IMSIMS--IIIIN=73N=73 58%58% .. 45%45% ..

MERCIMERCIN=141N=141

60%60%48%48%

.. 28%28% ..

N=164N=16455%55%

.. 36%36% ..

TrialTrial Trial DesignTrial Design

PROACTPROACT--IIIIJAMA 282 (1999) 2003JAMA 282 (1999) 2003--20112011

Randomized, IA proRandomized, IA pro--

IMSIMS--I, III, IIStroke 35 (2004) 904Stroke 35 (2004) 904--911911Stroke 37 (2006) 708Stroke 37 (2006) 708

Registry, IV tRegistry, IV t--PA + IAPA + IA

MERCIMERCIStroke 36 (2005) 1432Stroke 36 (2005) 1432--14381438

Registry, IA thrombecRegistry, IA thrombec

Multi MERCIMulti MERCIAJNR 27 (2006) 1177AJNR 27 (2006) 1177--11821182

Registry, IA thrombecRegistry, IA thrombec

MortalityMortalitySymptomaticSymptomatic

ICHICHBaselineBaselineNIHSSNIHSS

RxRx ContCont RxRx ContCont RxRx ContCont

25%25% 27%27% 10%10% 2%2% 1717 1717

16%16% .. 6.3%6.3% .. 1818 ..

16%16% .. 11%11% 1919 ..

44%44% .. 7.8%7.8% .. 2020 ..

34%34% .. ..2.4%2.4%

.. 1919 ..

K vs. IV heparinK vs. IV heparin

--PAPA

omy, IA lytics allowed, IV disallowedomy, IA lytics allowed, IV disallowed

omy, IA & IV lytics allowedomy, IA & IV lytics allowed


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PENUMBRA APENUMBRA A

An aspiration catheter, with a distal wiAn aspiration catheter, with a distal wikeep the catheter clear, and a graspingkeep the catheter clear, and a graspingdesigned to remove harder thrombus idesigned to remove harder thrombus iaspiration device fails to recanalize thaspiration device fails to recanalize th

Approved under the 510K regulations iApproved under the 510K regulations iJanuary 2008 as "substantially equivalJanuary 2008 as "substantially equivalanother currently approved mechanicaanother currently approved mechanica

(Concentric Medical Inc) for the indicat(Concentric Medical Inc) for the indicatrevascularization of patients with acutrevascularization of patients with acutischemic stroke secondary to large veischemic stroke secondary to large veocclusive disease within 8 hours of syocclusive disease within 8 hours of syonset.onset.

piration Devicepiration Device

e toe todevicedevicethethevessel.vessel.

nnnt" tont" to

l device,l device,

ion ofion of

selselptomptom


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Penumbra StudPenumbra StudPhase II studyPhase II study

125 patients at 24 internati125 patients at 24 internatiSingle arm trialSingle arm trialNIHSS >7NIHSS >7

TIMI 0 or 1TIMI 0 or 1Not eligible or no responseNot eligible or no response

11oo endpoints: revascularizendpoints: revascularizprocedural SAEs.procedural SAEs.

Company designed andCompany designed and

: ISC Feb. 2008: ISC Feb. 2008

onal centersonal centers

o iv TPAo iv TPA

tion (TIMI 2 or 3) andtion (TIMI 2 or 3) and

ponsored!ponsored!


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PENUPENURevascularization (TIMI 2 orRevascularization (TIMI 2 oraspiration device only verseaspiration device only verse< 0.0001),< 0.0001),

Adjunctive grasping device notAdjunctive grasping device not3.2% procedural serious adv3.2% procedural serious advthe 7.1% historical control.the 7.1% historical control.

Patient 2: SAH due to wirePatient 2: SAH due to wire Patient 3: ICH immediately follPatient 3: ICH immediately foll

MBRAMBRA): 82 percent of patients with): 82 percent of patients withthe 48.2% historical control (pthe 48.2% historical control (p

approved as too few patients testedapproved as too few patients testedrse events (SAE) rate versesrse events (SAE) rate verseshere were 4 SAEs:here were 4 SAEs:

,,

wing recanalizationwing recanalization


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PENUPENUFavorable outcomeFavorable outcome

at 30 days: 4 point improvemeat 30 days: 4 point improveme3 point

Mortality: 26.4% at 30 days aMortality: 26.4% at 30 days a

MBRAMBRA

t NIHHS at discharge or 30 day mRSt NIHHS at discharge or 30 day mRS

mRS


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1. Early changes with loss of s1. Early changes with loss of s lci and edema on the right sidelci and edema on the right side


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Surgery for AcutSurgery for AcutEmergent carotid endarteEmergent carotid endartethrombectomythrombectomy limited utilitylimited utility

typically following acute posttypically following acute post--

intraintra--arterial snares, jets, lasarterial snares, jets, las

HemicraniectomyHemicraniectomy To prevent herniation of thTo prevent herniation of th

strokestrokea salvage procedurea salvage procedure

randomized trial underwayrandomized trial underway

Ischemic StrokeIschemic Strokeectomy andectomy and

CEA occlusionsCEA occlusions

rs are being explored.rs are being explored.

brain following massivebrain following massive


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Heparin in AcuHeparin in AcuDVT prophylaxis

Progressing, stutterin

High degree carotid star oem o c stro e

Prosthetic valves

Vertebro-basilar ische

Acute partial stroke**

e Cerebral Ischemiae Cerebral Ischemia

, unstable ischemia

nosist m ng

ia

Anticoag latAnticoag lat

ion for Ac teion for Ac te


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AnticoagulatAnticoagulat

IschemiIschemiUrgentUrgent routineroutineanticoagulationanticoagulationoutcome or preventing early reoutcome or preventing early re

Possible indications regarding iPossible indications regarding ispecific patient groups unknowspecific patient groups unknow

LargeLarge--vessel atherothrombovessel atherothrombofrom post hoc data of the TOAST trifrom post hoc data of the TOAST tri

stroke 2stroke 2oo to occlusionto occlusion High risk ofHigh risk of

Not recommended for moderatNot recommended for moderat

High risk of intracranial bleeHigh risk of intracranial blee

Contraindicated within 24 hourContraindicated within 24 hourNO BOLUSNO BOLUS goal is PTT 1.5goal is PTT 1.5--2.0 times control2.0 times control

Adams HP Jr, et al. ASA Guidelines. Stroke. 2003;34:1056-

ion for Acuteion for Acute

StrokeStrokeith goal of improving neurologicith goal of improving neurologic

urrence not recommended.urrence not recommended.

mmediate anticoagulation inmmediate anticoagulation in

sissis l maybe benefit in acute carotid artery territoryl maybe benefit in acute carotid artery territory

recurrent embolismrecurrent embolism

or severe stroke.or severe stroke.

inging

of tPA.of tPA...

1083.

Results of AnResults of An

ticoagulation:ticoagulation:


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Results of AnResults of An

MetaMeta--aaNo significant difference in 2No significant difference in 2--weekweek

mortality (8.5% in AC group vsmortality (8.5% in AC group vs8.7% in controls)8.7% in controls)

Total new strokes identical betweenTotal new strokes identical between2 treatment rou s: 4.1%2 treatment rou s: 4.1%

No evidence of heterogeneityNo evidence of heterogeneityamong various studiesamong various studiesor agentsor agents

Sandercock P, et al. Stroke. 1999;30:248. Abstract.

ticoagulation:ticoagulation:

nalysisnalysis

ICH Ischemic Stroke

4

newstroke

0

1

2

3

No AC AC

Perce

ntexperienc

in


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Blood Pressure iBlood Pressure iAcute elevations of BP are common iAcute elevations of BP are common i

Seen in 85% of patientsSeen in 85% of patients

Often declines spontaneously inOften declines spontaneously in2424--48 hours48 hours

Cerebral autoregulation is defective iCerebral autoregulation is defective i

Acutely lowering BP can expand areAcutely lowering BP can expand are

Supported by PET studiesSupported by PET studies

Supported by clinical experiencSupported by clinical experienc

Supported by ASA guidelinesSupported by ASA guidelines

Ischemic StrokeIschemic Stroken stroke.n stroke.

firstfirst

n most stroke patients.n most stroke patients.

of ischemia.of ischemia.


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Mean value and 95% CIs of infarct volume on

admission. Castillo: Stroke, Volume 35(2).F

ays 4 to 7 by SBP (A) and DBP (B) levels on

bruary 2004.520-526


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BP RX in PatientsBP RX in Patients EliEli Before tPA treatmentBefore tPA treatment

Systolic >185 mm Hg or diastolicSystolic >185 mm Hg or diastolic

LabetalolLabetalol oror

NicardipineNicardipine

>185/110 mm Hg, do not adminis>185/110 mm Hg, do not adminis

During and after tPA treatment: monitDuring and after tPA treatment: monit180/1200180/1200

ible for Thrombolysisible for Thrombolysis

110 mm Hg110 mm Hg

er tPAer tPA

or blood pressure to keep underror blood pressure to keep underr

BP RX inBP RX in

PatientsPatients


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BP RX inBP RX in

Not Eligible foNot Eligible fo Systolic 22 r i t li >1

Labetalol 10Labetalol 10--20 mg IV over20 mg IV overevery 10 min, max 300 mg)every 10 min, max 300 mg)

Aim for 10%Aim for 10%--15% reducti15% reducti

Diastolic >140 mm HGDiastolic >140 mm HG

Nitroprusside (or nicardipineNitroprusside (or nicardipine

Aim for 10%Aim for 10%--15% reducti15% reducti

PatientsPatients

ThrombolysisThrombolysis20 mm Hg20 mm Hg

nless eviddence of end organnless eviddence of end organ

ypertensive encephalopathyypertensive encephalopathy

mm Hmm H

--2 min (may repeat or double2 min (may repeat or doubler Nicardipiner Nicardipine

on in blood pressureon in blood pressure

/labetalol))/labetalol))

on in blood pressureon in blood pressure


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Stroke SystStroke Syst ms of Carems of Care


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Efficacy versusEfficacy versus

Study is not theStudy is not the

EffectivenessEffectiveness

ain thing but action.ain thing but action.

Pirkei AvotPirkei Avot

Chapter 1Chapter 1

Median EDMedian ED rrival Timesrrival Times


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Median EDMedian ED

Based on Type of FiBased on Type of Fi

200

300

400

median

minutes

to ED arrival

0

100

911 (n=885; 45%)

Personal MD (n=196; 10%)

Other (n=84; 4%)

NINDS rt-PA Pilot Study. Barsa

rrival Timesrrival Times

st Medical Contactst Medical Contact

230

275350

120

Study Hospital (n=591; 30%)

Another Hospital (n=144; 7%)

WG et al Stroke 1994

Impact of rtImpact of rt--

A ProtocolsA Protocols


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Impact of rtImpact of rt

A Survey of NorthA Survey of NorthI T E M

C om m unity A w areness P rog

St roke Team s

tro e care m aps a go r t m s

R apid s troke i .d . program s

Stroke U ni ts

Neurologis ts

54 of 125 hospitals in 46 of 100 c

had rt-PA protocols Goldstei

A ProtocolsA Protocols

arolina Hospitalsarolina Hospitals% w ith

rt-PA vs .

wi thout

P va lue

am s 41 vs 17 0 .003

31 vs 8 0 .001

vs < .

33 vs 6 < 0 .001

33 vs 7 < 0 .001

78 vs 33 < 0 .001

unties with 74% of state pop.

LB et al Stroke 1998

Benefits of aBenefits of a troke Team introke Team in


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Acute TrAcute Tr112

121

60

80

100

120

140

24

0

20

40

Sx Onset to ED

Arrival

ED arriva

toMD exa

EMS Private Vehicle Stroke

atmentatment

50

74

115

32

l

ED arrival to

neuro exam

ED arrival to

CT

team present Stroke team absent

Bratina P et al Stroke 1995


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Outcomes foOutcomes fo

Decreased mortality:Decreased mortality:

Death or dependencyDeath or dependencyDecrease in Length oDecrease in Length o

CocCoc

Stroke UnitsStroke Units

Odds RatioOdds Ratio

0.830.83

0.750.75StayStay 22--11 days11 days

rane Database 1999rane Database 1999

Outcomes forOutcomes for Stroke UnitsStroke Units


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Outcomes forOutcomes forDeath or InstiDeath or Insti

MenMen

WomenWomen

75 yrs

Mild strokeMild stroke

Moderate strokeModerate stroke

Severe strokeSevere strokeCC

Stroke UnitsStroke Unitsutional Careutional Care

Odds RatioOdds Ratio

0.660.66

0.770.77

0.770.77

0.710.71

0.840.84

0.730.73

0.580.58chrane Database 1999chrane Database 1999

StrokeStroke enters:enters:


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The three LThe three LEmergent strokeEmergent stroke--ready hospitalsready hospitals Mainly for rural areasMainly for rural areas Stabilize stroke patientsStabilize stroke patients Use tPA then transfer out:Use tPA then transfer out:

drip and shipdrip and shipPrimary stroke centersPrimary stroke centers

Pprovide initial, acute carePprovide initial, acute care Admit patients to stroke unitAdmit patients to stroke unit

Comprehensive stroke centersComprehensive stroke centers

Care for complex patients (large ICare for complex patients (large I Interventional and other specializeInterventional and other specialize Team approach with stroke speciTeam approach with stroke speci

specialists and neurosurgeonsspecialists and neurosurgeons

ICH, intracerebral hemorrhage; IS, ischemic stroke; SAH, s

vels of Carevels of Care

, ICH, SAH), ICH, SAH)d treatments (coils, stents, etc)d treatments (coils, stents, etc)lists, neurointensivists, endovascularlists, neurointensivists, endovascular

ubarachnoid hemorrhage.

Emergent StrokeEmergent Stroke--ReRe dy Hospital (ESRH)dy Hospital (ESRH)


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Emergent StrokeEmergent Stroke ReRe

and Primary Sand Primary SStroke teamStroke team

Rapid head CTRapid head CT

Rapid laboratory testingRapid laboratory testing

Ability to give tPA and other acuteAbility to give tPA and other acutetherapiestherapies

Various disease erformanceVarious disease erformancemeasuresmeasures

Primary stroke centeralso provides:

Stroke unit

Neurosurgery within 2 hours

Alberts MJ, et al. JAMA. 2000;283(23):3102-3109.

National Institute of Neurological Disorders and Stroke.http://www.ninds.nih.gov/news_and_events/proceedings/sttm. Accessed January 21, 2010.

dy Hospital (ESRH)dy Hospital (ESRH)

troke Centers:troke Centers:Stroke protocolsStroke protocols

ED/EMS supportED/EMS support

Staff educationStaff education

Administrative supportAdministrative support

ESRH also provides:

Referral/transfer agreements with 1or more primary stroke centers

oke_2002/acute_stroke_choosing.h


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Primary StrPrimary Str

Stroke teamsStroke teams

Stroke unitStroke unitss

Written caremaps andprotocolsWritten caremaps andprotocols

mergency me ca serv cesmergency me ca serv ces

Emergency departmentEmergency department

Availability of neurosurgicalAvailability of neurosurgicalservicesservices

.

Alberts MJ, et al. JAMA. 2000;283(23):3102-3109.

ke Centerske CentersSupport of hospitalSupport of hospital

administrationadministrationNeuroimaging (CT/MR/etc)Neuroimaging (CT/MR/etc)

Laboratory servicesLaboratory services

Outcome/quality assurance andOutcome/quality assurance andimprovement processesimprovement processes

Continuing medical educationContinuing medical education

C t St t f St k C t C tifi ti P i


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About 600 PSCs certified by The Join

About 250 PSCs certified by state-ba

Many hospitals now going through re

Current Status of Stroke C

Stroke Cen

ew po n s o emp as s y

Dysphagia screening and docu tPA administration to eligible p Nursing knowledge of the patie

Federal government (CMS, NQF) willfor all patients

Commission (TJC)

ed organizations (NY, MA, FL)

ertification process

nter Certification: Primary

ers (PSCs)

mentationtients

nt care plan and protocols

begin looking at postdischarge outcomes

BAC Update to PS

Recommendations


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Stroke unit with telemetry

Stroke team response (in15 minutes

MRI with diffusion for hospitalized pa

Cardiac imaging

Document why eligible patients were

BAC Update to PS

National external certification

BAC, Brain Attack Coalition; PSC, primary stroke center.

tients and CTA or MRA

not given tPA

Recommendations

Joint Commission StaJoint Commission Sta

dardized Performancedardized Performance


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Joint Commission StaJoint Commission Sta

Measures for PrimMeasures for Prim Venous thromboembolism prophyVenous thromboembolism prophy

Discharged on antithrombotic theDischarged on antithrombotic the

Anticoagulation therapy for atrial fAnticoagulation therapy for atrial f

Thrombolytic therapyThrombolytic therapy

Antithrombotic therapy by end ofAntithrombotic therapy by end of

Dischar ed on statin medicationDischar ed on statin medication

Dysphagia screening*Dysphagia screening*

Stroke educationStroke education

Smoking cessation/advice/couSmoking cessation/advice/cou

Assessed for rehabilitationAssessed for rehabilitation

The Joint Commission Web site. http://www.jointcommissiohttp://manual.jointcommission.org/bin/view/Manual/Questio

* Will be retired in 2010.

dardized Performancedardized Performance

ry Stroke Centersry Stroke Centerslaxislaxis

apyapy

ibrillation/flutteribrillation/flutter

ospital day 2ospital day 2

seling*seling*

n.org/AboutUs/Fact_Sheets/psc_certification.htm.ns/UserQuestionId03Stk100036.


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TelemedicinTelemedicinVideo links are reasonableVideo links are reasonableperforming an exam with iperforming an exam with ireliability comparable to fareliability comparable to faexamexam

experienced stroke specialiexperienced stroke specialiTeleradiology is also a useTeleradiology is also a useacute stroke.acute stroke.

It is recommended that strIt is recommended that strspecialists using telemedispecialists using telemediopinion for/against TPA wopinion for/against TPA wexpertise not immediatelyexpertise not immediately

and Strokeand Strokeforforterter--raterratere to facee to face

tstsful adjunct inful adjunct in

kekeine provideine provideen onen on--sitesitevailablevailable

Early ManagemeEarly Manageme t of Acute Stroket of Acute Stroke


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Early ManagemeEarly Manageme

SummarSummarEvaluate candidacy for thEvaluate candidacy for th

CT: need to exclude ICHCT: need to exclude ICHEarly use of antiplatelet aEarly use of antiplatelet a

Early diagnostic studiesEarly diagnostic studies? Need for anticoagulatio? Need for anticoagulatio

Consider NPO status andConsider NPO status and

evaluationevaluation

t of Acute Stroket of Acute Stroke

ReviewReviewombolyticsombolytics

ents if not TPA candidateents if not TPA candidate

need for swallowingneed for swallowing

Early ManagemeEarly Manageme t of Acute Stroket of Acute Stroke


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SummarSummarMonitored bed (large strokes mayMonitored bed (large strokes may

ICP)ICP)

0.9% NS only!0.9% NS only!

Avoid (and treat) hypotensionAvoid (and treat) hypotension

vo aggress ve treatment o ypvo aggress ve treatment o yp

If neccesary, use an easily titratabIf neccesary, use an easily titratabor nitroprussideor nitroprusside

Except in thrombolysis cases, therExcept in thrombolysis cases, ther

pressurepressure

AHA guidelines suggest no rxAHA guidelines suggest no rx


ReviewReviewneed ICU bed for management ofneed ICU bed for management of

ertens on un ess g r s .ertens on un ess g r s .

e agent such as i.v. labetalol, hydralazine,e agent such as i.v. labetalol, hydralazine,

e is no absolute upper limit to the bloode is no absolute upper limit to the blood

unless SBP >220unless SBP >220




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y gy g

SummarSummarEarly PT/OT, Speech therapyEarly PT/OT, Speech therapy

Aspiration precautions/consiAspiration precautions/consiDVT prophylaxisDVT prophylaxis

EuglycemiaEuglycemia

NormothermiaNormothermia

ReviewReview, Rehab, Rehab

er NPO/swallower NPO/swallow


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ConclConcl>80 percent of all stroke is isch>80 percent of all stroke is ischembolic) in etiologyembolic) in etiology

Acute recanalizaiton is imperatiAcute recanalizaiton is imperati Intravenous TPA is the preferred tIntravenous TPA is the preferred t

Must be given within 3 hours of sMust be given within 3 hours of s

Can be given up to 4.5 hours in sCan be given up to 4.5 hours in s IntraIntra--arterial thrombolysis (pharmarterial thrombolysis (pharmfor patients with large strokes orfor patients with large strokes or

Despite above, stabilization forDespite above, stabilization for Avoid medical complicationsAvoid medical complications

Dont overtreat BPDont overtreat BP

DX and RX must be expeditedDX and RX must be expedited

sionssionsemic (atherothrombotic oremic (atherothrombotic or

vevereatment strategyreatment strategymptom onset with strict criteria applied formptom onset with strict criteria applied for

lected patientslected patientscologic and/or mechanical is an optioncologic and/or mechanical is an optionho are outside the iv TPA windowho are outside the iv TPA window

ALL stroke patients is indicatedALL stroke patients is indicated


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emergent management of acute ischemic stroke pdf version

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