Title: Stroke Care 2006: Clinical Consensus and Opportunities A Case Study to Challenge the Experts
1Stroke Care 2006 Clinical Consensus and
OpportunitiesA Case Study to Challenge the
Experts
2Clinical Decision Making in Emergency
MedicineAn Evidence-Based ConferencePonte
Vedra Beach, FLJune 15-17, 2006
3Thank you to AstraZeneca for their support of
this stroke educational meeting
4Panelists
- Andy Jagoda, MD, FACEP (Moderator)
Mount Sinai School of Medicine - Thomas G. Brott, MD Mayo Clinic Jacksonville
- E. Bradshaw Bunney, MD, FACEP University of
Illinois at Chicago - J. Stephen Huff, MD, FACEP
University of Virginia - Edward P. Sloan, MD, MPH, FACEP
University of Illinois at Chicago
5Disclosures
- Andy Jagoda, MD
- AstraZeneca
- Thomas G. Brott, MD
- None
- E. Bradshaw Bunney, MD
- AstraZeneca, Genentech consultant
- J. Stephen Huff, MD
- None
- Edward P. Sloan, MD, MPH
- None
6Global Objectives
- Improve acute stroke patient care
- Minimize morbidity and mortality
- Expedite disposition
- Optimize resource utilization
- Enhance our job satisfaction
7Session Activities
- Present a relevant clinical case
- Poll the audience about care
- Discuss the questions
- Understand areas of consensus
- Explore areas of uncertainty
- Go forth and prosper
8Case Presentation
- 62 year-old professor has an apparent stroke
while teaching at the local community college. - Contact to the local EMS base station occurs
within 15 minutes of the onset of symptoms. - He arrives at the closest ED within 30 minutes of
symptom onset.
9Case Presentation
- VS 178/80 RR 18 P 96 Temp 98.6
- Cardiopulmonary exam OK
- Mental Status OK
- Neurological Exam
- Awake and alert
- R facial weakness
- Slurred speech
- Right visual field neglect
- Unable to purposefully move RUE / RLE
10Question TIA ED Visit
- Had this patient presented to the ED two weeks
earlier with dizziness and numbness in his R
upper extremity, what would be your approach?
11Question TIA ED Visit
- I admit all TIA patients regardless of the
severity of the symptoms.
12Question TIA ED Visit
- B. I only admit those patients who have clear
motor weakness or visual symptoms (amaurosis
fugax) because of a greater stroke risk.
13Question TIA ED Visit
- C. I might consider sending this patient home,
but only if I have completed a cranial CE and an
evaluation of the carotids (Doppler, CTA, MRA).
14Question TIA ED Visit
- D. I would send this patient home with aspirin
therapy and arrange that a physician complete a
TIA work-up as an outpatient.
15Question TIA ED Visit
- E. I dont really have an opinion on what to do
with this TIA patient, and so would depend on my
neurologist for a disposition decision.
16Question TIA ED Visit
- I admit all TIA patients.
- I only admit those patients who have clear motor
weakness or visual symptoms. - Send home after a cranial CT and a carotid
evaluation. - Send home, outpatient TIA workup.
- No opinion, ask the neurologist.
17Question EMS Triage
- Regarding EMS triage, should this patient be
18Question EMS Triage
- Transported to the closest hospital?
19Question EMS Triage
- B. Diverted to the closest primary stroke center?
20Question EMS Triage
- C. Diverted to the closest tertiary center with
24/7 interventional radiology?
21Question EMS Triage
- D. Diverted to the closest
comprehensive stroke center?
22Question EMS Triage
- E. Asked to finish his class first?
23Question EMS Triage
- Closest hospital
- Closest primary stroke center
- Closest 24/7 IR tertiary center
- Closest comprehensive stroke center
- Asked to finish the class first
24Question Inter-hospital Transfer
- If this patient is transported to the closest ED
of a hospital with no specific stroke team or
protocol, which of the following best describes
circumstances when transfer to a tertiary or
stroke center should take place for this stroke
patient?
25Question Inter-hospital Transfer
- A. There are no indications for inter-hospital
transfer to take place.
26Question Inter-hospital Transfer
- B. The patient should be transferred after IV tPA
is administered.
27Question Inter-hospital Transfer
- C. Transfer should take place only if IV tPA is
not indicated and CNS intra-arterial thrombolytic
therapy or thrombus removal is likely.
28Question Inter-hospital Transfer
- D. Transfer should take place for all patients if
the time from symptom onset is between three and
ten hours in order to allow advanced diagnostics
to be provided acutely.
29Question Inter-hospital Transfer
- E. Transfer to a primary stroke center should
take place for all stroke patients, regardless of
the time of symptom onset, whether IV tPA has
been provided, and whether an acute clot
intervention is contemplated
30Question Inter-hospital Transfer
- F. I have no idea when inter-hospital transfer
should take place for patients such as this one.
31Question Inter-hospital Transfer
- No indications
- After IV tPA is administered.
- IV tPA is not indicated and CNS intra-arterial
thrombolytic therapy or thrombus removal is
likely - Symptoms 3-10 hours, diagnostics
- Transfer all stroke patients
- I have no idea
32Cincinnati Prehospital Stroke Scale
One positive possible stroke
3311 elements of a Primary Stroke CenterJAMA 2000
2833102-3109
- EMS integrated into the acute stroke response
- Stroke team available 24 / 7
- Written care protocols
- ED integrated into the acute stroke team
- Stroke unit
- Neurosurgical services available within 2 hours
- Commitment from the institution
- Neuroimaging interpreted within 45 min of arrival
- Laboratory services with rapid turn around of
tests - CQI program including a database or registry
- Continuing education program
34NINDS Symposium 2002Improving the Chain of
Recovery for Acute Stroke in Your Community
- ED basic
- Recognizes that not all EDs can provide
thrombolytic care - Stabilization ABC / BP / glucose / temp
- Transfer protocols
- Primary Stroke Center
- Comprehensive Stroke Center
- Tertiary care center
- Advanced stroke expertise in neuroimaging,
neurosurgery, interventional neuro-radiology
35Stroke Centers
- Improves outcomes?
- Newell et al. clinical efficiency tools improve
stroke management in a rural southern health
system. Stroke 1998 291092-1098 - Wentworth et al. Implementation of an acute
stroke program decreases hospitalization cost and
length of stay. Stroke 1996 271040-1043. - Douglas et al. Do the brain attach coalitions
criteria for stroke centers improve care for
ischemic stroke? Neurology 2005 64 422-427 - Implementation increased incidence of t-PA use
36AHRQ 127 Acute Stroke
- Are designated centers effective in reducing
stroke related disability and mortality? - No studies were identified
- Studies have shown that stroke teams decrease the
time to evaluation - Lattimore et al showed that creation of stroke
team increased tPA use from 1.5 to 10.5 of
acute stroke patients seen
37IV tPA Utilization Cleveland Clinic Health
System
- July 1997 - June 1998
- 70 pts treated with IV tPA
- 1.8 ischemic strokes
-
- 11.1 of ischemic strokes arriving lt 3 hrs
- 31 selected protocol deviations
- 16 symptomatic
- intracranial hemorrhage
- July 1999 - June 2000
- 53 pts treated with IV tPA
- 2.4 ischemic strokes
-
- 23.4 of ischemic strokes arriving lt 3 hrs
(53/226) - 17 selected protocol deviations
- 6.5 symptomatic
- intracranial hemorrhage
Katzan et al, Stroke 200334799-800
38JCAHO Disease Specific Care Certification
- Joint initiative between ASA and JCAHO
- Voluntary participation
- 94 accredited hospitals
- 36 site visits in progress
- 718 applications pending
- Premise is that accreditation process will drive
quality measures and improve outcomes - No emergency medicine society has endorsed this
initiative - t-PA controversy
- Overcrowding
- Medical legal implications
39Question Use of the NIHSS
- Which of the following describes your views
regarding the use of the NIHSS in evaluating
stroke severity and the indications for various
stroke therapies?
40Question Use of the NIHSS
- A. Every emergency physician should know how to
calculate the NIHSS for patients such as this
one, since it is the standard of care for
determining stroke severity and the need for any
and all stroke therapies.
41Question Use of the NIHSS
- B. It is obvious how severe this patients stroke
is, and the need for all potential stroke
therapies can be determined clinically without
actually calculating the NIHSS.
42Question Use of the NIHSS
- C. The NIHSS can be reliably estimated by
determining symptom severity in four categories
motor, speech, mental status, and visual/neglect.
43Question Use of the NIHSS
- D. The NIHSS is a research tool that can be
calculated retrospectively as needed as long as
the neurological exam in the ED is documented
appropriately.
44Question Use of the NIHSS
- E. When I am considering IV tPA, I just quickly
calculate the NIHSS using Internet tools.
45Question Use of the NIHSS
- F. What does NIHSS stand for, anyways?
46Question Use of the NIHSS
- NIHSS is the standard of care
- Determine Rx clinically, no NIHSS
- Estimate NIHSS in 4 clinical areas
- Calculate retrospectively from exam
- Quickly calculate NIHSS with Internet
- What does NIHSS stand for?
47Question Patient NIHSS
- What is the approximate NIHSS of this patient?
- Awake and alert
- R facial weakness
- Slurred speech
- Right visual field neglect
- Unable to purposefully move his RUE / RLE
48Question Patient NIHSS
- 0-5
- 5-10
- 10-15
- 15-20
- Greater than 20
49Question Use of Scales
- Regarding the use of stroke outcome scales such
as the Modified Rankin Scale (MRS) or the Barthel
Index (BI), which of the following is your
clinical approach?
50Question Use of Scales
- A. I use these scales in assessing stroke patient
severity in the ED.
51Question Use of Scales
- B. I understand the MRS and the BI, and I use
them to help in assessing the effectiveness of
new stroke therapies from published clinical
trials.
52Question Use of Scales
- C. I do not have any idea how these outcome
scales are utilized, either in the ED or after
hospital disposition.
53Question Use of Scales
- D. These scales correlate with the NIHSS, making
their use superfluous.
54Question Use of Scales
- E. I have not ever heard of these scales, let
alone use them!
55Question Use of Scales
- I use these scales in the ED
- Scales assess the effectiveness of new stroke
therapies - No idea how these outcome scales are utilized
- Scales correlate with the NIHSS, making their use
superfluous - I have never heard of these stroke scales
56The utility of clinical scales
- Allow gross quantification of injury/pathology
- Aid in communication to consultants
- Can be used to track improvement or deterioration
in the acute treatment phase - Can be used to track outcome
- Can be useful research tools
Adapted from slide set of Kama Guluma, MD
57The NIH Stroke Scale
Adapted from slide set of Kama Guluma, MD
58The NIHSS
- Level of consciousness
- Gaze
- Visual fields
- Facial strength
- Arm strength
- Leg strength
- Limb ataxia (FNF, heel-down-shin)
- Sensation (pinch/pinprick)
- Language (re aphasia)
- Dysarthria
- Extinction/inattention (bilat sensory)
Maximum Score 42
Maximum score from ischemic stroke 31
59The NIH Stroke Scale
LEVEL OF CONSCIOUSNESS
60The NIH Stroke Scale
GAZE VISUAL FIELDS
61The NIH Stroke Scale
FACIAL MOTOR
62The NIH Stroke Scale
MOTOR OF THE ARM MOTOR OF THE LEG ATAXIA
63The NIH Stroke Scale
SENSORY
64The NIH Stroke Scale
LANGUAGE
65The NIH Stroke Scale
DYSARTHRIA
66The NIH Stroke Scale
EXTINCTION/NEGLECT
67What the NIHSS score means to the EP
- NIHSS 1 - 4 mild stroke
- NIHSS 5 -15 moderate stroke
- NIHSS 15 20 moderate to severe stroke
- NIHSS gt 20 severe stroke
- Prognosis likelihood of favorable outcome
- NIHSS lt 10 60 70
- NIHSS gt 20 4 -16
68What the NIHSS score means to the EP
- Chance of ICH with tPA
- NIHSS lt 10 3
- NIHSS gt 20 17
Stroke. 2003341056 1083.
69Consideration the low NIHSS score stroke with
a devastating effect on livelihood
70(No Transcript)
71Functional Outcome Scales
- Modified Rankin scale (mRS)
- Barthel Index (BI)
- Glasgow Outcome Scale (GOS)
- Utilize scored assessments of patients
functional status - Can be used to gauge
- pre-morbid baseline
- outcome
72Modified Rankin Scale
Score Description
6 Dead
5 Severe disability bedridden, incontinent, and requiring constant nursing care and attention
4 Moderately severe disability unable to walk without assistance and unable to attend to own bodily needs without assistance
3 Moderate disability requiring some help, but able to walk without assistance
2 Slight disability unable to carry out all previous activities, but able to look after own affairs without assistance
1 No significant disability despite symptoms, able to carry out all usual duties and activities
0 No symptoms at all
Good outcome score of 0 - 1
73Barthel Index
Feeding 0 unable 5 needs help cutting, spreading butter, etc, or requires modified diet 10 independent
Bathing 0 dependent 5 independent (or in shower)
Grooming 0 needs help with personal care 5 independent face/hair/teeth/shaving (implements provided)
Dressing 0 dependent 5 needs help but can do about half unaided 10 independent (including buttons, zips, laces, etc)
Bowels 0 incontinent (or needs enemas) 5 occasional accident 10 continent
74Barthel Index
Bladder 0 incontinent, or catheterized and unable to manage alone 5 occasional accident 10 continent
Toilet use 0 dependent 5 needs some help but can do something alone 10 independent (on and off, dressing, wiping)
Transfers (bed to chair and back) 0 unable, no sitting balance 5 major help (1 or 2 people, physical), can sit 10 minor help (verbal or physical) 15 independent
Mobility (on level surfaces) 0 immobile or lt50 yards 5 wheelchair-independent, including corners, gt50 yards 10 walks with help of 1 person (verbal or physical) gt50 yards 15 independent (but may use any aideg, stick) gt50 yards
Stairs 0 unable 5 needs help (verbal, physical, carrying aid) 10 independent
100 point scale good outcome 95 - 100
75Glasgow Outcome Scale
Score Description
1 DEAD
2 VEGETATIVE STATE Unable to interact with environment unresponsive
3 SEVERE DISABILITY Able to follow commands/ unable to live independently
4 MODERATE DISABILITY Able to live independently unable to return to work or school
5 GOOD RECOVERY Able to return to work or school
76Functional Scales and tPA Outcome
- NINDS tPA trial
- 13 absolute increase in mRS 0 1 in treatment
group - 12 increase in BI 95-100 in treatment group
- Means 9 patients need to be treated for one
improvement in outcome (NNT 9)
771-Year Outcome in NINDS trial
Kwiatkowski TG, et al. N Engl J Med.
19993401781-1787.
78Looking at NINDS data more closelyThe sliding
scale dichotomy endpoint
NNT 3
Saver J, 31st International Stroke Conference,
Kissimmee, FL, Feb 2006
79Summary
- The NIHSS helps quantify and stratify acute
stroke - Key aspects of the stroke-focused (NIH scale)
neuro exam - LOC, vision, motor, coordination, sensation,
language - Understanding the mRS, BI, and GOS can aid
interpretation of outcome in stroke clinical
trials.
80Question Use of IV tPA
- This patients stroke is deemed to be moderate to
severe in its severity and is a suitable
candidate for thrombolytic therapy with IV tPA .
Which of the following is your viewpoint
regarding the use of IV tPA given the published
efficacy data?
81Question Use of IV tPA
- A. If IV tPA is indicated, I use it because the
clinical data supports its use and I am
adequately supported in its use.
82Question Use of IV tPA
- B. Although I am not opposed to the use of tPA, I
do not use it often because patients rarely meet
the criteria for use in the ED.
83Question Use of IV tPA
- C. I try not to use tPA because the published
efficacy data does not adequately support its use
and because I am not well supported to use it.
84Question Use of IV tPA
- D. I simply am so concerned about the risk of a
symptomatic ICH that I cannot bear to use this
drug when treating stroke patients such as this
one.
85Question Use of IV tPA
- E. I leave the tPA use decision to the stroke
team or neurology consultant.
86Question Use of IV tPA
- F. Havent we discussed tPA enough already?
87Question Use of IV tPA
- Clinical data supports its use
- Patients rarely meet the criteria
- Published efficacy data does not adequately
support its use - Concerned about the risk of a symptomatic ICH
- Decided by the stroke team
- Havent we discussed tPA enough already?
88Question tPA Data
- Regarding the reanalysis of the NINDS tPA
clinical trial data and the phase IV tPA use
data, which of the following describe your
understanding of the info?
89Question tPA Data
- A. I understand that the reanalysis of the NINDS
data suggests that there is a real treatment
effect and that the phase IV data confirms that
the outcomes of the NINDS study can be replicated
in clinical practice.
90Question tPA Data
- B. I know that the NINDS clinical trial data was
confirmed, but the numbers are too small to allow
for widespread clinical use, even with
confirmatory phase IV clinical data.
91Question tPA Data
- C. I have trouble believing phase IV reports,
since they are inherently biased, making the use
of tPA still somewhat experimental in my practice.
92Question tPA Data
- D. I do not have enough familiarity with the
reanalysis or the phase IV publications, such
that I have not changed my tPA clinical practice.
93Question tPA Data
- E. Why was the data reanalyzed, and what is a
phase IV study?
94Question tPA Data
- I understand the reanalysis of the NINDS data
phase IV data - Numbers are too small to allow for widespread
clinical use. - I have trouble believing phase IV reports and
have not changed - I do not have enough familiarity
- What is a phase IV study?
95NINDS Trial Results Patients with Favorable
Outcome
t-PA Placebo t-PA Placebo t-PA Placebo
No. of patients 312 157 145
Modified Rankin Scale 40 28
Glasgow Outcome Scale 43 32
NIHSS 34 20
Symptomatic ICH (within 36 hr) 6.4 0.6
Death (by 90 days) 17 21
96IV Thrombolysis
- 14 absolute increase for the best clinical
outcomes (mRS of 0-1). - Benefit Need to treat eight patients with tPA
in order to have one additional patient with this
best outcome. - 6 absolute increase in the number of symptomatic
ICH. - Harm Will have one symptomatic ICH for every 16
patients treated with tPA. - 2 patients will have a minimal or no deficit for
every patient with a symptomatic ICH
97Meta-analyses
98Meta-analyses
- Wardlaw et al.
- Net benefit despite hazards
- For 1000 treated up to 6hrs
- 55 improve, 20 die
- Heterogeneity, wide CI make results unreliable
- Additional trial data required
99Meta-analyses
- Graham et al., 15 published reports
- ICH rate 5.2, total death rate 13.4
- All better than NINDS
- Lysis can be used safely across wide variety of
practice settings
100Meta-analyses
- Hacke et al.
- 6 randomized trials
- Sooner thrombolytics given the greater the
benefit - Particularly when given within 90 minutes of onset
101CONTROVERSY Meta-analysis
- Hoffman and Cooper
- Pooled data can not replace new or confirmatory
data - Meta-analyses did not include streptokinase
trials which were negative - No reason to exclude streptokinase
102Phase IV tPA trials
Author Eligible patients Patients receiving tPA() Mean time to Rx Median NIHSS score Favorable outcome ICH Symptomatic ICH Protocol deviation
NINDS 312 14 31-54 10.9 6.4
Chiu 1035 30(2.9) 237 14 63 10 6.6
Tanne 189 gt2 11-15 9 5.8 30
Wang 900 57(6.3) 228 15 44-54 9 5 9
Buchan 1540 68(4.4) 15 95 31 9 16
Albers 389 244 13 35-43 11.5 3.3 33
Katzan 3948 70(1.8) 12 22 15.7 50
Chapman 2556 46(1.8) 245 14 30-48 9 2.2 17
Grotta 1689 269(16) 217 14 33 4.5 13
Bravata 63 15 17 6 67
Total 12,282 928(5.8) 225 10-15 33-95 9.6 5.2 13-67
103Re-analysis
104NINDS Re-analysis
- Does the protocol work?
- Do subgroup imbalances invalidate the entire
trial? - What about BP?
105Baseline NIHSS Imbalance
NIHSS Score NIHSS Score 0-5 6-10 11-15 16-20 gt 20
No. of patients Placebo (n312) 16 83 66 70 77
No. of patients t-Pa (n310) 42 67 65 73 63
Chi-square (4 DF) 14.8 p 0.005
106OTT Analysis Report
- Review Committee had concerns about analyzing OTT
as a continuous variable - Uncertainty about the exact time of stroke onset.
- OTT distribution was nonlinear with 25 of all
the patients having OTT values of either 89 or 90
minutes.
107Symptom onset vs Cumulative
108NINDS ICH Analysis
- Risk Factors for ICH
- Baseline NIHSS gt 20
- Age gt 70 years
- Ischemic changes present on initial CT
- Glucose gt 300 mg/dl (16.7 mmol/L)
of Risk Factors of patients treated with t-PA (n310) Symptomatic ICHs ( of placebo patients with ICH) Percentage ()
0 114 2 (1) 1.8
1 144 7 (1) 4.9
gt 1 52 11 21.2
109IV Thrombolysis
- The independent reanalysis of the NINDS tPA
clinical trial confirms the results from the
initial NEJM publication - Support the use of tPA in stroke patients within
three hours of symptom onset - Number needed to treat calculation based on this
reanalysis confirms that approximately 8-10
patients need to be treated with tPA in order to
cause one extra patient to have the best clinical
outcome. - 2 patients will improve for every one that
develops a symp ICH
110EM Physicians and Lysis
- Brown et al.
- 1,105 of 2600 ACEP members responded
- 40 not likely to use thrombolytics
- 65 risk of ICH
- 23 perceived lack of benefit
- 12 both
- Upper limit ICH rate 3.4
- Lowest acceptable relative improvement 40
111Informed Consent Documentation
- With tPA, there is a 30 greater chance of a good
outcome at 3 months - With tPA use, there is 10x greater risk of a
symptomatic ICH (severe bleeding stroke) - Mortality rates at 3 months are the same
regardless of whether tPA is used - 2 patients will have a minimal or no deficit for
everyone patient with a symptomatic ICH
112Documentation
- Just as important
- The patient is NOT a candidate for tPA because
113Question Utilizing Tests
- Many diagnostic tests are available when
attempting to intervene positively in acute
stroke patients. If the initial CT is negative
for hemorrhage, how do you utilize tests such as
MRI, MRA, CTA, or cerebral angiography when
treating stroke patients?
114Question Utilizing Tests
- A. I do not know when these tests are indicated
in acute ischemic stroke patients, and so do not
order them in the ED.
115Question Utilizing Tests
- B. I am aware that these tests may enhance the
ability to diagnose the vascular lesion
responsible for the stroke, but I rely on my
neurology consultants to determine the need for
these tests.
116Question Utilizing Tests
- C. I know that these tests are most useful when
considering advanced stroke therapies such as IA
thrombolysis or clot retrieval, and only order
them when the patient is due to have an
interventional radiology procedure.
117Question Utilizing Tests
- D. I order these tests often in order to expedite
the diagnostic workup of my ED stroke patients,
whether these patients are to receive IV tPA or
who might receive an acute interventional
radiology procedure.
118Question Utilizing Tests
- E. Have any of these diagnostic tests been proven
to be effective at improving outcome in stroke
patients?
119Question Utilizing Tests
- I do not order them in the ED.
- I rely on my neurology consultants.
- I order them when the patient is due to have an
interventional radiology procedure. - I order these tests often.
- Have these tests been proven to be effective?
120Question Advanced Therapies
- There are many options that exist after the
three-hour IV tPA window, including IA
thrombolysis, the Merci clot retrieval device,
and devices that enhance cerebral blood flow.
What is your clinical practice regarding these
advanced stroke therapies?
121Question Advanced Therapies
- A. I do not have a clear understanding of these
advanced therapies, and do not access them for my
stroke patients.
122Question Advanced Therapies
- B. I know of these therapies, but my
understanding is that they are experimental in
nature and are not a part of the standard of care.
123Question Advanced Therapies
- C. I have noted these therapies to be used by my
neurology consultants on occasion, but I am not
sure of the indications for their use.
124Question Advanced Therapies
- D. I understand the utility of these
interventions, and I aggressively pursue them for
my stroke patients who do not meet the IV tPA
criteria.
125Question Advanced Therapies
- E. Have any of these therapies been proven to be
effective in any published clinical trials?
126Question Advanced Therapies
- Do not access them.
- Experimental in nature.
- used by my neurology consultants on occasion.
- I aggressively pursue them.
- Have any of these therapies been proven to be
effective in any published clinical trials?
127Foundation for Education and Researchin
Neurological EmergenciesStroke Care 2006
Clinical Consensus and Opportunities June 16,
2006Treatment of Stroke Beyond Three Hours
Thomas G. Brott, MD, Professor of Neurology Mayo
Clinic Jacksonville College of Medicine
128Results I
- 2776 patients
- Over 300 hospitals
- 18 countries
- Median age 68 years
- Median baseline NIHSSS 12
129Results II
- Median onset-to-treatment time 4 hours
- Of the 929 (33) treated within 3 hours,
one-third were from studies other than NINDS
130Results IV
- Odds Ratios for Favorable Outcome
- Time Odds Ratio 95 Conf. Interval
- 0-90 2.8 1.8, 4.5
- 91-180 1.5 1.1, 2.1
- 181-270 1.4 1.1, 1.9
- 271-360 1.2 0.9, 1.5
131What about IA thrombolysis?
132(No Transcript)
133(No Transcript)
134PROACT II
- Stroke within 6 hours
- 2/3 treated with pro-UK (121)
- 1/3 treated with placebo (59)
135Results of ProACT II
- 40 of the UK patients had a good recovery
- 25 of the control patients had a good recovery
- P.04
- Absolute difference15...NNT of 7
- FDA did not approve
136A score of ?2 (yellow) on the modified Rankin
scale (mRS) indicates a favorable outcome of
slight or no disability. A score of 6
represents death. R-proUK recombinant
prourokinase
137Beyond Thrombolysis Combination Therapy,
Devices, and Other Approaches
138(No Transcript)
139Concentric Retriever Device With Nitinol Coil
(White Arrow) and Inflated Balloon (Black Arrow)
Leary MC, et al. Ann Emerg Med. 2003
Jun41(6)838-46
140MERCI Recanalization and Outcomes
ICA (n47) MCA (n80)
BL NIHSS 19 20
TIMI II/III 53 45
NIHSS 10 pts. 33 29
Sx ICH 15 4
Death 51 39
About half were TIMI III At 90 days
141ICH in 11 (8) of patients
142Question Clinical Guidelines
- Regarding ischemic stroke patients, what is your
understanding and use of clinical guidelines?
143Question Clinical Guidelines
- A. I am not aware of any clinical guidelines that
direct my care of ischemic stroke patients.
144Question Clinical Guidelines
- B. I am sure that there are guidelines that exist
from organizations such as the American Stroke
Association, but I do not use them because
primarily my neurology consultants utilize these
guidelines.
145Question Clinical Guidelines
- C. I am familiar with guidelines that direct
stroke patient care, and I refer to them on
occasion in order to optimize my acute care.
146Question Clinical Guidelines
- D. I follow clinical guidelines and protocols in
my ED because our hospital has integrated them
into clinical policies for the institution.
147Question Clinical Guidelines
- E. I wish that there were guidelines that would
direct my treatment of stroke complications such
as elevated blood pressure.
148Question Clinical Guidelines
- Not aware of any clinical guidelines.
- My neurology consultants utilize these
guidelines. - I refer to them on occasion.
- Our hospital has integrated them.
- I wish that there were guidelines.
149Question Optimal Therapies
- Regarding neuroprotection in acute ischemic
stroke patients, what is your understanding of
current optimal therapies?
150Question Optimal Therapies
- A. I am not aware of any specific neuroprotection
therapies for ischemic stroke patients.
151Question Optimal Therapies
- B. I believe that the only useful therapies
involve ASA use and blood pressure and glucose
management in the majority of ischemic stroke
patients.
152Question Optimal Therapies
- C. Besides BP and glucose control, I consider
optimal cerebral blood flow to be another
critical neuroprotectant, and I pursue aggressive
thrombolysis and clot retrieval of the target
vessel in order to achieve it.
153Question Optimal Therapies
- D. I am aware of the trials of specific
neuroprotectants, and I utilize them in my
clinical practice.
154Question Optimal Therapies
- E. I do not believe that neuroprotection is
possible. Once the initial damage is done, there
is no way to protect the infarct zone or ischemic
penumbra.
155Question Optimal Therapies
- Not aware of any therapies.
- Only useful therapies involve ASA use and blood
pressure and glucose management. - Optimal cerebral blood flow is another critical
neuroprotectant. - I utilize them.
- I do not believe that neuroprotection is possible.
156Question Stroke and ICH
- Consider if this patient had been on warfarin and
had an intracerebral hemorrhage of the left
temporal lobe of 3 cm diameter associated with
moderate edema and mass effect. What might be
your management of this ICH patient?
157Question Stroke and ICH
- I would admit this patient to neurosurgery for
further orders.
158Question Stroke and ICH
- B. I would transfer this patient to another
hospital because I dont have neurosurgery
coverage and/or it is our institutions protocol.
159Question Stroke and ICH
- C. I would be able to manage BP, ICP, the airway,
and ICH complications in the ED prior to
disposition to another service for admission.
160Question Stroke and ICH
- D. Not only would I manage the patient as in (C.)
above, I would also discuss the use of Factor
VIIa with neurosurgery in this ICH patients
care.
161Question Stroke and ICH
- D. I am aware of ICH management guidelines,
including those that govern the care of patients
with an elevated INR, and would follow these
guidelines in managing this patient.
162Question Stroke and ICH
- A. Admit to neurosurgery.
- B. Transfer for neurosurgery care.
- C. I can manage pt prior to transfer.
- D. FVIIa is an issue I would address.
- E. I know how to manage elevated INRs in pts who
are on warfarin.
163Conclusions
- Important EM patient clinical area
- Many questions
- Some areas of consensus
- Many areas of opportunity
- Further work is needed
- The interest is there
164Questions?Thank you!
ferne_at_ferne.org edsloan_at_uic.edu www.ferne.org
ferne_pv_2006_strokecare_final 3/15/2014
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