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

5
(No Transcript)
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Unpublished data from the GC/NKSS Kissela et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. 200435426-31.
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
Michigans Stroke Belt
Source The Atlas of Stroke Mortality
9
(No Transcript)
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 gt 220 or DBP gt 120
• If receiving thrombolytics treat if
• PreRx SBP gt 185 DBP gt 110
• PostRx SBP gt 180 DBP gt 105

12
Doesnt 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
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
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

42
(No Transcript)
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_at_umich.edu
• Please feel free to contact me if you would like
  an educational program at your site!