ACUTE STROKE IDENTIFICATION AND TREATMENT (

1
ACUTE STROKE IDENTIFICATION AND TREATMENT
(TIME IS BRAIN)Andy Jagoda, MD,
FACEPDepartment of Emergency MedicineMount
Sinai School of MedicineNew York, New York
2
A 58 yo man experiences one half hour of numbness
and weakness in his left arm. When he arrives in
the ED his symptoms have resolved. PMH positive
for CAD. Meds Enalapril. PE no focal
deficits. ECG NSR.Should this patient be
admitted to the hospital?

• a. yes
• b. no

3
The patient is discharged for an outpatient
workup. Three weeks later he develops left face
and arm weakness. EMS is called. Which of the
following is the best choice?

• a. He should be taken to the closest hospital
• b. He should be taken to the closest hospital
  with a designated stroke team

4
The patient arrives in the ED, one hour after
onset of symptoms, with no improvement. Blood
pressure since EMS arrived has remained 170/100.
Which of the following is the best blood pressure
management?

• a. sl nitroglycerin
• b. po clonidine
• c. iv labetolol
• d. no treatment

5
A CT is obtained within 90 minutes of symptom
onset It is read by a neuroradiologist and shows
no signs of edema, infarct, or hemorrhage. Which
of the following would you recommend?

• a. t-PA
• b. aspirin
• c. heparin
• d. a plus b or c
• e. supportive care

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INTRODUCTION

• Stroke is the 3ird most common cause of death
• Second most common cause for patient to be in a
  nursing home
• 500,000 - 700,000 strokes / year
• 80 - 90 Ischemic
• 10 - 20 Hemorrhagic or SAH
• 30 Mortality within 3months
• Leading cause of disability
• 3 million with stroke related disability
• Estimated 40 billion annual heath care cost
• TAYLOR ET AL. STROKE 1996271459

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The Facts

• TIAs
• 20 of stroke patients have a preceding TIA
• 75 resolve in lt15 minutes 97 lt3 hours
• Stroke
• 5.4 recurrent symptomatic stroke within 1 year
• 28 mortality within 1 year (40-60 related to
  stroke)
• Acute stroke
• ICH within 36 hours 1 symptomatic, 4
  asymptomatic
• 25 have little or no disability at 3 months
• 25 have mild to moderate disability at 3 months
• 30 have severe disability
• 20 dead at 3 months

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Transient Ischemic Attack

• Cerebrovascular event with deficit lt24 hours
• Symptoms in a vascular territory
• Risk of stroke
• 25 by 5 years
• 15 by 1 year
• 10 at 3 months
• 5 at 48 hours
• Anticoagulation indicated in atrial fibrillation,
  patent foramen ovale, carotid / vertebral artery
  stenosis
• Endarterectomy reduces risk by 10 at 2 years

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Transient Ischemic Attack

• Benefits of hospitalization
• Facilitates diagnostic evaluation
• Allows observation and rapid management for
  stroke
• Hospitalization indicated for
• Suspected cardio-embolism
• Patients gt 60
• Diabetes
• Symptom duration gt 10 minutes
• Weakness
• Speech impairment
• Initiate anti-platelet therapy (aspirin,
  clopidigrel)

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SUBTYPES OF STROKE

• HEMORRHAGIC
• INTRACEREBRAL HEMORRHAGE
• SUBARACHNOID HEMORRHAGE
• ISCHEMIC LARGE ARTERY ATHEROSCLEROSIS WITH
  THROMBOEMBOLISM
• SMALL VESSEL DISEASE
• CARDIOEMBOLISM
• NONARTHEROSCLEROTIC VASCULOPATHIES
• HYPERCOAGULABLE STATES

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GOALS IN STROKE MANAGEMENT

• DEFINE ETIOLOGY
• CONSIDER CONDITIONS THAT MASQUERADE AS STROKE
  COMPLICATED MIGRAINE, TODDS PARALYSIS,
  HYPOGLYCEMIA, FUNCTIONAL
• DO NO HARM
• DO NOT OVERTREAT BLOOD PRESSURE
• MANAGE BLOOD SUGAR
• LIMIT INFARCT SIZE
• ROLE OF THROMBOLYTICS
• NEUROPROTECTIVE AGENTS
• PREVENT COMPLICATIONS
• INITIATE EARLY REHABILITATION

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NINDS PROCEEDINGS 1997

• PUBLIC EDUCATION
• PREHOSPITAL EMERGENCY RESPONSE
• DESIGNATED STROKE CENTERS
• EMERGENCY DEPARTMENTS
• HOSPITAL STROKE UNITS
• REHABILITATION

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PUBLIC EDUCATION

• NINDS STROKE TRIAL, 17,000 PATIENTS, ONLY 3.6
  WERE ELIGIBLE FOR TREATMENT
• AGGRESSIVE PUBLIC CAMPAIGNS HAVE DECREASED TIME
  OF ONSET TO TIME OF ED ARRIVAL TO lt 3 HOURS IN
  50 OF PATIENTS
• FACTORS ASSOCIATED WITH DELAY
• NO SYMPTOM RECOGNITION
• LIVING ALONE
• NIGHTTIME ONSET
• CALL TO MD
• MORRIS ET AL. ACAD EMERG MED 19963539
• BARSAN ET AL. ARCH INT MED 19931532558

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CHAIN OF RECOVERY

• MI TRAUMA STROKE
• RAPID ON-SCENE IDENTIFICATION OF LIFE-THREATENING
  PROBLEMS
• RAPID EVACUATION TO APPROPRIATE FACILITY WITH
  PRENOTIFICATION
• RAPID DIAGNOSIS
• RAPID DEFINITIVE INTERVENTIONS
• SPECIALIZED IN-PATIENT MANAGEMENT
• REHABILITATION

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THE PUBLIC MESSAGE

• WEAKNESS OR NUMBNESS ON ONE SIDE OF THE BODY
• DIFFICULTY WITH VISION
• DIFFICULTY WITH SPEECH OR UNDERSTANDING
• UNUSUALLY SEVERE HEADACHE
• DIZZINESS OR UNSTEADINESS

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STROKE IS A BRAIN ATTACK.CALL 911PUBLIC
SERVICE ANNOUNCEMENT. JANUARY 1998
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EMS DISPATCH IN ACUTE STROKE

• PRIORITY DISPATCH SYSTEMS
• GOAL TO SEND THE RIGHT THINGS TO THE RIGHT
  PEOPLE AT THE RIGHT TIME IN THE RIGHT WAY
  (NHAAP, NIH, 1994)
• 911
• STILL NOT AVAILABLE TO 15 OF POPULATION
• BASIC 911 REQUIRES PATIENT PARTICIPATION
• ADVANCED 911, CALLER ID
• EMS DISPATCHERS IDENTIFY ONLY 51 OF STROKES
  (KOTHARI. STROKE 199627171)
• ARRIVAL TO ED FROM SYMPTOM ONSET
• 7 WITHIN 1 HR (JORGESEN. NEUROLOGY 199647383)
• 2.6 HOURS (BARSAN. ARCH INT MED 19931532558)

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PREHOSPITAL CARE IN STROKE

• UP TO 25 OF PATIENTS WITH ACUTE STROKE REQUIRE
  ADVANCED CARE DURING TRANSPORT
• AIRWAY MANAGEMENT
• SEIZURE CONTROL
• RECOGNITION OF MI AND DYSRHYTHMIAS
• KOTARI ET AL. STROKE 199526937

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PREHOSPITAL STROKE SCALE

• FOCUSED EXAM TO MINIMIZE FIELD TIME AND TO
  ACTIVATE STROKE TEAM
• FACIAL DROOP
• SYMMETRICAL MOVEMENT
• ASYMMETRIC MOVEMENT
• MOTOR WEAKNESS
• NO MOVEMENT OR PRONATOR DRIFT
• SPEECH REPEAT A PHRASE
• SLURS WORDS, USES INAPPROPRIATE WORDS, OR IS
  UNABLE TO SPEAK
• KOTARI ET AL. ACAD EMERG MED 19974986

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THE STROKE TEAM / STROKE CENTERS

• GOAL
• To provide comprehensive, coordinated care
• To identify candidates for thrombolytics within
  3 hours
• TEAM
• Physicians with expertise in stroke
• Nurse
• CT personnel
• AVAILABILITY
• 24 hours / day / 7 days a week
• Alberts et al. Recommendations for the
  establishment of primary stroke centers. JAMA
  2000 28331-2-3109

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IDEAL RESPONSE TIMES

• ED arrival within one hour of symptoms
• Evaluation within 10 minutes of arrival
• Stroke team notification within 15 min
• CT within 25 minutes
• CT interpretation within 45 minutes
• Thrombolytics for eligible patients within 60
  minutes
• Transfer to a stroke unit within 3 hours or
  arrival

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THE STROKE TEAM

• EMS NOTIFICATION
• TEAM ACTIVATION
• STANDING ORDERS
• VITAL SIGN MONITORING
• RAPID GLUCOSE DETERMINATION
• NEUROLOGICAL MONITORING
• ECG / CARDIAC MONITORING
• IV ACCESS
• LABORATORY STUDIES CBC, LYTES, PT/PTT, TYPE AND
  SCREEN
• PORTABLE CXR
• HEAD CT

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EMERGENCY DEPARTMENT APPROACH TO STROKE HISTORY

• TIME OF ONSET
• HEAD TRAUMA
• SEIZURE
• MEDICATIONS USE OF ANTICOAGULANTS
• SYMPTOMS SUGGESTIVE OF MI
• CHEST PAIN, PALPITATIONS, SOB
• SYMPTOMS SUGGESTIVE OF HEMORRHAGE
• SEVERE HEADACHE
• NECK STIFFNESS / PAIN
• NAUSEA / VOMITING

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ED APPROACH TO STROKE PHYSICAL

• ABCS
• Vital signs (BP both arms presence of fever)
• LOC (when depressed, consider other diagnoses)
• Trauma exam
• Neck exam
• Cardiopulmonary exam
• Neurologic exam
• Glasgow coma scale
• NIHSS 15 Item measure 42 Points
• lt 4 Not a candidate for thrombolytics
• gt 22 Increased risk for hemorrhage

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NIH Stroke Scale

• Level of consciousness
• Orientation (month and age)
• Follow commands
• Best gaze
• Visual fields
• Facial palsy

• Motor arm
• Motor leg
• Limb ataxia Sensory
• Best language
• Dysarthria
• Extinction and inattention (neglect)

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Stroke Mimics

• Todds paralysis
• Complicated migraine
• Nonconvulsive status epilepticus
• Neuropathy
• Hypoglycemia
• Hyperglycemia

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Stroke Localization Pearls

• Aphasia usually corresponds to left hemispheric
  stroke (right sided weakness)
• Neglect (hemi-attention) usually indicates right
  hemispheric stroke
• Patients usually look towards the lesion
• Crossed signs indicated brainstem involvement
• Vertigo of central origin almost always is
  associated with other cranial nerve deficits
• Vertical nystagmus is posterior circulation
  ischemia until proven otherwise

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CONTROVERSIES IN STROKE MANAGEMENT

• USE OF DEXTROSE
• MANAGEMENT OF BLOOD PRESSURE
• USE OF THROMBOLYTICS
• USE OF HEPARIN

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BLOOD PRESSURE MANAGEMENT IN ISCHEMIC STROKE

• Loss of autoregulation in ischemic brain CBF
  depends on arterial BP to maintain cerebral
  perfusion
• Most ischemic stroke patients have a history of
  hypertension and need higher CPP
• In general, there is a spontaneous decline in BP
  over time
• Lowering BP may exacerbate brain ischemia
• ADAMS ET AL. STROKE 1994251901
• STRANDGAARD. CIRCULATION 197653720

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BLOOD PRESSURE MANAGEMENT IN ISCHEMIC STROKE

• Systolic 185 - 220, Diastolic 105 - 120 Do not
  treat for the first hour (consider
  benzodiazepines) if persists, IV Labetolol, 10
  mg.
• Systolic gt 220 mm Hg or diastolic 121 - 140 2
  readings 20 min apart Start Labetolol 10 MG IV.
  Patients requiring more than 2 doses are not
  candidates for t-PA
• Diastolic gt 140 mm Hg 2 readings 5 minutes
  apart Start Nitroprusside. Patient is not a
  candidate for t-PA

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BLOOD PRESSURE MANAGEMENT IN ISCHEMIC STROKE

• HYPOTENSION IN ACUTE STROKE
• DEHYDRATION
• ARRHYTHMIA
• DIMINISHED CARDIAC OUTPUT
• TREAT UNDERLYING CAUSE
• FLUIDS
• RHYTHM CONTROL
• PRESSORS

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BLOOD PRESSURE MANAGEMENT IN HEMORRHAGIC STROKE

• NO STUDIES TO SHOW LOWERING BP DECREASES RISK OF
  REBLEEDING OR IMPROVES OUTCOME
• NINDS RECOMMENDS INTERVENTION WHEN THE SYSTOLIC gt
  180, DIASTOLIC gt 130
• GOAL IS TO LOWER THE BP TO A MAP OF 130 mm Hg (10
  - 20)
• NITROPRUSSIDE OR LABETOLOL

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Use of Thrombolytics Review of the literature
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NINDS

• Randomized, double blind study 624 patients
• t-PA .9 mg/kg (max 90 mg) within 3 hours onset
• Statistically significant benefit in outcome at 3
  and 12 months
• No change in mortality and a decrease in LOS

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Alpers et al. The standard treatment with
Alteplase to reverse stroke study (STARS). JAMA
2000 2831145-1150

• Prospective, multi-center phase IV study 2/97 -
  12/98
• Designed to assess safety profile and outcome
  findings.
• 57 or 83 centers in ATLANTIS participated
• 389 patients
• median time of tx 2 hours and 44 minutes
• median NIHSS score 13 (vs 14 in NINDS)
• 19 NIHSS score gt20 (vs 20 in NINDS)
• 6 with cerebral edema on initial CT (vs 4
  NINDS)
• 3 day rate ICH
• 3.3 symptomatic (vs 6.4 NINDS)
• 7 asymptomatic
• 1.5 major systemic bleeding

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Alpers et al. The standard treatment with
Alteplase to reverse stroke study (STARS). JAMA
2000 2831145-1150

• 35 violations of the NINDS protocol
• 13 treated beyond the 3 hour window
• 9 received anticoagulants within 24 hours
• 7 treated with BPs gt 185 mm Hg
• Symptomatic ICH occurred in 3.9 (vs 3.1 trend
  towards significance)
• 30 day outcome (NINDS measured at 90 days)
• 13 mortality
• 35 very favorable outcome Rankin lt1
• 8 functionally independent Rankin 1-2
• 12 moderate disability Rankin 3
• 31 moderate to severe disability Rankin 4

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Alpers et al. The standard treatment with
Alteplase to reverse stroke study (STARS). JAMA
2000 2831145-1150

• Predictors of favorable outcome
• NIHSS score of 10 or less
• Absence of specific abnormalities on the baseline
  CT (hypodensity gt 1/3 MCA associated with ICH)
• Age lt 86
• Odds of recovery (OCD)
• For every 5 point increase in baseline NIHSS
  score, patients had a 22 decrease in the OCD
• NIHSS scores greater than 10 had a 75 decrease
  in the OCD
• Every 10 point increase in baseline mean BP
  decreased the OCD by 19
• Results replicated the NINDS study

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Katzan et al. Use of t-PA The Cleveland
experience. JAMA 2000 2831151-1158

• Retrospective review of Cleveland experience
  using data from stroke registry from 29
  hospitals,over a one year period, 1997-1998
• Stroke patients identified using ICD-9 codes
• 4345 ischemic strokes
• 17 admitted within 3 hours
• 70 patients received t-PA 1.8 of all stroke
  patients, 10.4 of eligible patients
• 16 of 29 hospitals used t-PA
• 669 matched patients who did not receive t-PA

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Katzan et al. Use of t-PA The Cleveland
experience. JAMA 2000 2831151-1158

• In-hospital mortality 16 t-PA vs 7.1 no t-PA
• 5 mortality in the general stroke population
• ICH rate 22 15.7 symptomatic
• 50 of deaths were in the symptomatic ICH group
• Patients treated with t-PA were discharged home
  significantly less often than those not treated

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Katzan et al. Use of t-PA The Cleveland
experience. JAMA 2000 2831151-1158

• 50 violation of treatment guidelines
• 37 treated with antithrombotics
• 13 treated outside of 3 hours
• 7 SBP gt 185 or DBP gt110
• NIHSS score not documented in 60
• median score of 12
• Deviation in BP treatment / monitoring 86

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Katzan et al. Use of t-PA The Cleveland
experience. JAMA 2000 2831151-1158

• Limited data on stroke severity
• 50 receiving treatment had deviations from the
  NINDS treatment standards
• no significant correlation between deviations and
  symptomatic ICH
• Neurologic outcomes were not tracked

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DECIDING TO USE THROMBOLYTICS

• UP TO 20 OF PATIENTS ARE INCORRECTLY DIAGNOSED
  AS HAVING A STROKE
• EXPERTISE IN STROKE MANAGEMENT NEEDED
• EXCLUSION
• CT SIGNS OF HEMORRHAGE OR INFARCTION
• UNDETERMINED TIME OF ONSET
• UNCONTROLLED HYPERTENSION
• RAPIDLY RESOLVING NEURO DEFICITS
• UNRESOLVING NEURO DEFICIT LASTING gt 90 MIN, LESS
  THAN 3 ARE TIAs

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STROKE UNITS

• IMPROVES OUTCOME
• OPTIMIZES CHANCE OF RECOVERY
• MINIMIZES COMPLICATIONS
• DECREASE LENGTH OF HOSPITAL STAY
• PROVIDES ONGOING MONITORING
• NEUROLOGIC DETERIORATION (4-8 SEIZURE)
• CARDIAC DYSRHYTHMIAS (CARDIAC ETIOLOGY IN 14 OF
  POST-STROKE DEATHS)
• DECREASES INCIDENCE OF PE, PNEUMONIA (30 OF
  STROKE DEATHS)
• FACILITATES DIAGNOSTIC WORK-UP
• ENSURES EARLY REHABILITATION, PATIENT AND FAMILY
  EDUCATION
• LANGHORNE ET AL. LANCET 1993342395

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CONCLUSIONS

• New treatment for stroke makes rapid diagnosis
  critical
• Chain of survival begins with public education
  and rapid access to definitive care
• Identification of hospitals prepared to provide
  comprehensive care is fundamental
• Stroke teams are critical to ensure efficient
  stroke management
• Continuous quality improvement programs are
  needed to assess effectiveness and identify needs