Stroke 2006: Optimal ED Patient Management Strategies Case Studies to Challenge the Experts

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Stroke 2006 Optimal ED Patient Management
Strategies Case Studies to Challenge the
Experts
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New York ACEP Scientific AssemblyLake George,
NYJuly 5-7, 2006
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Thank you to AstraZeneca for their support of
this stroke educational meeting
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Panelists

• Andy Jagoda, MD, FACEP
• Mount Sinai School of Medicine
• Peter L. Shearer, MD, FACEP
• Mount Sinai School of Medicine
• Edward P. Sloan, MD, MPH, FACEP
  University of Illinois at Chicago

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Disclosures

• Andy Jagoda, MD
• AstraZeneca, FERNE
• Peter L. Shearer, MD, FACEP
• None
• Edward P. Sloan, MD, MPH
• FERNE

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Prior Panelists

• 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

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Prior Panelists Disclosures

• 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

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Global Objectives

• Improve acute stroke patient care
• Minimize morbidity and mortality
• Expedite disposition
• Optimize resource utilization
• Enhance our job satisfaction

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Session 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

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Case 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.

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Case 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

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Question 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?

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Question TIA ED Visit

• I admit all TIA patients regardless of the
  severity of the symptoms.

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Question 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.

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Question 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).

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Question 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.

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Question 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.

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Question 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.

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Question EMS Triage

• Regarding EMS triage, should this patient be

20
Question EMS Triage

• Transported to the closest hospital?

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Question EMS Triage

• B. Diverted to the closest primary stroke center?
  

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Question EMS Triage

• C. Diverted to the closest tertiary center with
  24/7 interventional radiology?

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Question EMS Triage

• D. Diverted to the closest
  comprehensive stroke center?

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Question EMS Triage

• E. Asked to finish his class first?

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Question EMS Triage

• Closest hospital
• Closest primary stroke center
• Closest 24/7 IR tertiary center
• Closest comprehensive stroke center
• Asked to finish the class first

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Question 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?

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Question Inter-hospital Transfer

• A. There are no indications for inter-hospital
  transfer to take place.

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Question Inter-hospital Transfer

• B. The patient should be transferred after IV tPA
  is administered.

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Question 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.

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Question 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.

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Question 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

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Question Inter-hospital Transfer

• F. I have no idea when inter-hospital transfer
  should take place for patients such as this one.

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Question 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

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Cincinnati Prehospital Stroke Scale
One positive possible stroke
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11 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

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NINDS 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

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Stroke 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

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AHRQ 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

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IV 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
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JCAHO 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

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Question 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?

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Question 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.

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Question 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.

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Question 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.

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Question 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.

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Question Use of the NIHSS

• E. When I am considering IV tPA, I just quickly
  calculate the NIHSS using Internet tools.

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Question Use of the NIHSS

• F. What does NIHSS stand for, anyways?

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Question 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?

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Question 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

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Question Patient NIHSS

• 0-5
• 5-10
• 10-15
• 15-20
• Greater than 20

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Question 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?

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Question Use of Scales

• A. I use these scales in assessing stroke patient
  severity in the ED.

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Question 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.

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Question Use of Scales

• C. I do not have any idea how these outcome
  scales are utilized, either in the ED or after
  hospital disposition.

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Question Use of Scales

• D. These scales correlate with the NIHSS, making
  their use superfluous.

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Question Use of Scales

• E. I have not ever heard of these scales, let
  alone use them!

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Question 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

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The 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
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The NIH Stroke Scale
Adapted from slide set of Kama Guluma, MD
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The Stroke-focused Neuro ExamThe 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
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The NIH Stroke Scale
LEVEL OF CONSCIOUSNESS
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The NIH Stroke Scale
GAZE VISUAL FIELDS
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The NIH Stroke Scale
FACIAL MOTOR
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The NIH Stroke Scale
MOTOR OF THE ARM MOTOR OF THE LEG ATAXIA
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The NIH Stroke Scale
SENSORY
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The NIH Stroke Scale
LANGUAGE
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The NIH Stroke Scale
DYSARTHRIA
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The NIH Stroke Scale
EXTINCTION/NEGLECT
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What 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

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What the NIHSS score means to the EP

• Chance of ICH with tPA
• NIHSS lt 10 3
• NIHSS gt 20 17

Stroke. 2003341056 1083.
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Consideration the low NIHSS score stroke with
a devastating effect on livelihood
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(No Transcript)
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Functional 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

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Modified Rankin Scale
Good outcome score of 0 - 1
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Barthel Index
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Barthel Index
100 point scale good outcome 95 - 100
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Glasgow Outcome Scale
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Functional 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)

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1-Year Outcome in NINDS trial
Kwiatkowski TG, et al. N Engl J Med.
19993401781-1787.
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Looking at NINDS data more closelyThe sliding
scale dichotomy endpoint
NNT 3
Saver J, 31st International Stroke Conference,
Kissimmee, FL, Feb 2006
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Summary

• 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.

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Question 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?

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Question 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.

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Question 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.

85
Question 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.

86
Question 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.

87
Question Use of IV tPA

• E. I leave the tPA use decision to the stroke
  team or neurology consultant.

88
Question Use of IV tPA

• F. Havent we discussed tPA enough already?

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Question 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?

90
Question 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?

91
Question 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.

92
Question 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.

93
Question 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.

94
Question 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.

95
Question tPA Data

• E. Why was the data reanalyzed, and what is a
  phase IV study?

96
Question 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?

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NINDS Trial Results Patients with Favorable
Outcome
98
IV 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

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Meta-analyses
100
Meta-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

101
Meta-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

102
Meta-analyses

• Hacke et al.
• 6 randomized trials
• Sooner thrombolytics given the greater the
  benefit
• Particularly when given within 90 minutes of onset

103
CONTROVERSY 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

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Phase IV tPA trials
105
Re-analysis
106
NINDS Re-analysis

• Does the protocol work?
• Do subgroup imbalances invalidate the entire
  trial?
• What about BP?

107
Baseline NIHSS Imbalance
Chi-square (4 DF) 14.8 p 0.005
108
OTT 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.

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Symptom onset vs Cumulative
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NINDS 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)

111
IV 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

112
EM 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

113
Informed 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

114
Documentation

• Just as important
• The patient is NOT a candidate for tPA because

115
Question 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?

116
Question 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.

117
Question 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.

118
Question 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.

119
Question 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.

120
Question Utilizing Tests

• E. Have any of these diagnostic tests been proven
  to be effective at improving outcome in stroke
  patients?

121
Question 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?

122
Question 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?

123
Question Advanced Therapies

• A. I do not have a clear understanding of these
  advanced therapies, and do not access them for my
  stroke patients.

124
Question 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.

125
Question 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.

126
Question 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.

127
Question Advanced Therapies

• E. Have any of these therapies been proven to be
  effective in any published clinical trials?

128
Question 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?

129
Foundation 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
130
Results I

• 2776 patients
• Over 300 hospitals
• 18 countries
• Median age 68 years
• Median baseline NIHSSS 12

131
Results II

• Median onset-to-treatment time 4 hours
• Of the 929 (33) treated within 3 hours,
  one-third were from studies other than NINDS

132
Results 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

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What about IA thrombolysis?
134
(No Transcript)
135
(No Transcript)
136
PROACT II

• Stroke within 6 hours
• 2/3 treated with pro-UK (121)
• 1/3 treated with placebo (59)

137
Results 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

138
A 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
139
Beyond Thrombolysis Combination Therapy,
Devices, and Other Approaches

140
(No Transcript)
141
Concentric Retriever Device With Nitinol Coil
(White Arrow) and Inflated Balloon (Black Arrow)
Leary MC, et al. Ann Emerg Med. 2003
Jun41(6)838-46
142
MERCI Recanalization and Outcomes
About half were TIMI III At 90 days
143
ICH in 11 (8) of patients
144
Question Clinical Guidelines

• Regarding ischemic stroke patients, what is your
  understanding and use of clinical guidelines?

145
Question Clinical Guidelines

• A. I am not aware of any clinical guidelines that
  direct my care of ischemic stroke patients.

146
Question 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.

147
Question 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.

148
Question Clinical Guidelines

• D. I follow clinical guidelines and protocols in
  my ED because our hospital has integrated them
  into clinical policies for the institution.

149
Question Clinical Guidelines

• E. I wish that there were guidelines that would
  direct my treatment of stroke complications such
  as elevated blood pressure.

150
Question 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.

151
Question Optimal Therapies

• Regarding neuroprotection in acute ischemic
  stroke patients, what is your understanding of
  current optimal therapies?

152
Question Optimal Therapies

• A. I am not aware of any specific neuroprotection
  therapies for ischemic stroke patients.

153
Question 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.

154
Question 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.

155
Question Optimal Therapies

• D. I am aware of the trials of specific
  neuroprotectants, and I utilize them in my
  clinical practice.

156
Question 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.

157
Question 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.

158
Question 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?

159
Question Stroke and ICH

• I would admit this patient to neurosurgery for
  further orders.

160
Question 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.

161
Question 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.

162
Question 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.

163
Question 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.

164
Question 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.

165
70 yo man with HTN and DM on aspirin has a small
left parietal hemorrhagic stroke. Which of the
following do you recommend?

• Supportive care only
• DDAVP
• PCC
• rFactor VII

166
70 yo man with HTN and DM on coumadin has a
small left parietal hemorrhagic stroke. Which of
the following do you recommend?

• Supportive care only
• DDAVP
• PCC and Vit K
• rFactor VII and Vit K
• FFP and Vit K

167
70 yo man with HTN and DM receives r-tPA during
the infusion his mental status declines and
repeat CT shows a hemorrhagic stroke. Which of
the following do you recommend?

• FFP
• cryoprecipitate
• PCC and Vit K
• rFactor VII and Vit K

168
Conclusions

• Important EM patient clinical area
• Many questions
• Some areas of consensus
• Many areas of opportunity
• Further work is needed
• The interest is there

169
Questions?Thank you!
ferne_at_ferne.org edsloan_at_uic.edu www.ferne.org
ferne_nyacep_2006_stroke_finalcd
11/16/2009 946 PM