Hemiparesis: The Emerging Role of the Emergency Physician in Stroke Management Edward Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois College of Medicine-Chicago Chicago, IL

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Hemiparesis The Emerging Role of the Emergency
Physician in Stroke Management Edward Sloan,
MD, MPHAssociate ProfessorDepartment of
Emergency MedicineUniversity of Illinois College
of Medicine-ChicagoChicago, IL
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Objectives

• Present clinical case history
• Review Emergency Department HP
• Examine tPA clinical data
• Discuss tPA use in ischemic stroke
• Review other therapies for ischemic stroke
• Answer clinically relevant questions

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Case

• A 70 year old female developed acute onset of
  left arm weakness that lasted approximately 15
  minutes and then gradually resolved.  She chose
  to ignore the event and did well until three
  weeks later she developed complete paralysis of
  the left arm and pronounced weakness of the left
  leg neither resolved and approximately 90
  minutes into the event she called EMS.  Past
  medical history included hypertension and COPD. 
  Medications metoprolol, hydrochlorthiazide, and
  atrovent.

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Case

• On exam, BP 200/120, P 68, RR 18, T 98, and
  pulse oximetry showed 94 saturation.  The
  patient appeared alert though responses were
  slow.  The patient had bilateral carotid bruits,
  clear lungs, and a regular rate and rhythm. There
  was no facial asymmetry, upper extremity motor
  5/5 on the right and 0/5 on the left lower
  extremity motor 5/5 on the right and 3/5 on the
  left.  Sensory was intact to light touch and
  pinprick.  DTRs were 2/2 on the left and 0/2 on
  the right.  Planter reflex was downgoing on the
  right and upgoing on the left.

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Acute Ischemic Stroke Questions

• What are the epidemiology etiology?
• What are the key elements of the exam?
• What is the NIH stroke scale?
• What did the NINDS trial show?
• How should tPA be used by the EM MD?
• What about hemorrhagic conversion?
• What about other therapies?

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Acute Stroke Epidemiology

• 700,000 Cases annually
• 20 mortality within one year
• 30 billion annual costs
• Ischemic and hemorrhagic strokes

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Acute Ischemic StrokeEtiology

• Thrombotic, embolic, hypoperfusion
• Majority are vessel thrombosis
• Clot formation on diseased vessel
• 20 are embolic, from heart, great vessels
• Hypoperfusion with cardiogenic shock

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Acute Ischemic Stroke Syndromes

• Anterior cerebral
• Middle cerebral
• Posterior cerebral
• Vertebrobasilar
• Basilar artery occlusion
• Cerebellar
• Lacunar
• Arterial dissection

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Acute Stroke Historical Elements

• When did symptoms begin? Onset?
• Prior history of similar symptoms?
• When was the patient last seen normal?
• Risk factors?
• Medical hx that would preclude tPA use?

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Acute Stroke Physical Exam

• Vital signs, pulse ox, accucheck
• HEENT Pupils, papilledema, airway
• Neck Bruits, nuchal rigidity
• Chest Rales (CHF, aspiration)
• Cardiac Gallops, murmurs

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Acute Stroke Physical Exam

• Abd Evidence of AAA
• Ext Evidence of CHF, DVT
• Skin Evidence of infectious etiology
• Neuro CN, motor, sensory, reflexes,
  cerebellar, visual, language, neglect,
  mental status

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Neurologic Exam Cranial Nerves

• CN Anterior vs. brainstem?
• Anterior Contralateral CN deficits
• Brainstem Ipsilateral CN deficits

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Neurologic Exam Motor

• Motor CN, upper lower ext
• CN Eye motor (Bells)
• Upper Pronator drift
• Lower Leg lift

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Neurologic Exam Sensory

• Sensory Light touch, pinprick
• Graphesthesia

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Neurologic Exam Reflexes

• Normal vs. pathologic
• Normal Corneal, gag, DTRs
• Pathologic Babinski, Chadduck

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Neurologic Exam Cerebellar

• Truncal ataxia
• Ataxic gait
• Rhomberg

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Neurologic Exam Visual

• Visual field deficit
• Homonomous hemianopsia
• Neglect of one side

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Neurologic Exam Language

• Dysarthria Poor speech, motor dysfunction
• Aphasia Disturbed language processing
• Expressive cant speak
• Receptive cant process the spoken word

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Neurologic Exam Mental Status

• Level of consciousness (AVPU)
• Alert
• Responds to verbal
• Responds to painful
• Unresponsive

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Neurologic Exam NIH Stroke Scale

• 13 item scoring system, 7 minute exam
• Integrates neurologic exam components
• CN, motor, sensory, cerebellar, visual,
  language, LOC
• Maximum score is 31, signifying severe stroke
• Minimum score is 0, a normal exam
• Scores greater than 15-20 are more severe

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Acute Ischemic StrokeNINDS Clinical Trial of tPA

• Treatment within 180 minutes
• 0.9 mg/kg of tPA
• Two part study
• Endpoint favorable outcome at 3 months
• Also examined mortality, hemorrhage

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NINDS Clinical Trial of tPA Results

• Good outcome 30 more patients
• Odds of favorable outcome 1.7 (1.2-2.6)
• 10x greater hemorrhage risk (6.4 vs. 0.6)
• Comparable 3 month mortality (17 vs. 21)
• Conclusion tPA worth the hemorrhage risk,
  since there is clear benefit

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NINDS Clinical Trial of tPAClinical Upshot

• tPA must be considered
• Patient selection is very difficult
• Must maximize risk/benefit ratio
• Must avoid hemorrhage, if possible
• Need adequate severity, but not too severe
• Less than 2 of patients will meet criteria

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NINDS Clinical Trial of tPATiming Issues

• Early EMS contact is key
• Door to CT and CT read time important
• Is there time for a neurologist to consult?
• A stroke team helps
• The 3 hour window is not the only issue

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NINDS Clinical Trial of tPAClinically Relevant
Issues

• Histories are unreliable
• Timing issues hard to press for stroke
• Patient selection is painfully difficult
• Every CT has a hypodense area
• Tendency not to intervene
• First do no harm
• What we did vs. what was destined to be

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tPA in Acute Ischemic StrokeClinical
Documentation Issues

• Document that tPA was considered
• If not used, state explicitly why the pt did
  not meet criteria or why it was deferred
• When explaining, tell the four key points
• 30 greater chance of good outcome
• 10 fold greater risk of bleeding
• Same mortality rate, despite bleeding risk
• Explain why mortality is comparable

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tPA in Acute Ischemic StrokeOther Relevant
Studies

• ECASS No efficacy, higher mortality
• IA tPA Effective, feasible
• ATLANTIS 5 hour window not possible
• Cleveland Non-supportive tPA data
• 2 treated, 50 standard of care deviation
• 16 bled, 3x higher in-hospital mortality
• STARS Favorable outcome and mortality

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Acute Ischemic Stroke Goals of Other Therapies

• Recanalization
• Stop ischemic cascade
• Minimize hemorrhage
• Minimize morbidity and mortality

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Acute Ischemic StrokeOther Therapies

• LMW heparin Possibly effective
• IST study ASA reduces death stroke
  recurrence by 1
• PROACT II IA prourokinase improves outcome
• STAT Ancrod (pit viper venom) improves
  outcome, but causes hemorrhage
• Neuroprotectants May provide benefit

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Acute Ischemic StrokeOther Issues

• MR Imaging Feasible, assists pt selection
• Admission need Still must admit TIA/CVA pts
• No reason not to admit CVAs
• Cant predict progression, complications
• Data less clear for TIAshome observation?
• Need HMO experience to be documented

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Acute Ischemic StrokeCase Management

• Get the CT scan ASAP
• Control the blood pressure
• Start making calls PMD, family, neurologist
• Find out the CT results
• Decide risk/benefit
• Discuss with pertinent decision makers

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Acute Ischemic StrokeSpecific Case Outcome

• CT obtained quickly
• BP controlled with time SL NTG
• NIH stroke scale 15
• CT showed ?? Low density area
• Neurologist not inclined to treat
• Family defers tPA after consultation
• Some long term deficit, physical therapy

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Acute Ischemic Stroke Conclusions

• Ischemic stroke is a big problem
• There is significant morbidity mortality
• tPA is effective in a narrowly defined group
• Must aggressively work to get tPA used
• Other therapies hold promise

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Acute Ischemic Stroke Recommendations

• Better public education
• More timely EMS activation
• More analysis of tPA use re optimal patients
• Rapid MR imaging
• Dvlp other therapies, esp neuroprotectants

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All are true statement about acute ischemic
stroke except

• a. There are three major categories thrombotic,
  embolic, and hypoperfusion.
• b. The majority of all strokes are caused by
  vessel thrombosis.
• c. The symptoms of ischemic stroke develop over
  minutes to hours.
• d. The most common source of emboli are the
  heart and major vessels.
• e. Middle cerebral artery infarction is
  associated with ipsilateral weakness and
  numbness.