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Acute Myocardial Infarction

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Title: Acute Myocardial Infarction


1
Advances in the Role of Emergency Medicine
Management of Cerebrovascular Events
Edward C. Jauch, MD MS FACEP Assistant Professor
Director of Research Department of Emergency
Medicine University of Cincinnati College of
Medicine Faculty, Greater Cincinnati / Northern
Kentucky Stroke Team
2
Disclosure
  • Industry
  • Boehringer-Ingelheim Speakers Bureau
  • Biosite Consultant Site investigator
    (BRAIN)
  • Johnson Johnson Consultant Site
    investigator (AbESTT-II)
  • Novo Nordisk Consultant Site investigator
    (FAST)
  • American Heart Association
  • ASA and ACLS Stroke Guidelines Committees
  • Editorial Board, CPR and ECC Guidelines
  • Various administrative AHA committees
  • National Institutes of Health funding (acute
    trials)
  • CLEAR, IMS-II/III, SPOTRIAS, THIS, MR RESCUE

3
Introduction
  • Review advances in Emergency Medicine management
    of cerebrovascular events
  • Acute ischemic stroke
  • Intracerebral hemorrhage
  • Subarachnoid hemorrhage
  • Transient ischemic attack
  • Highlight the role of Emergency Medicine in goal
    directed brain resuscitation

4
Neurologic Emergency Management
5
Where to Start, Learn from OthersTrauma and AMI
  • Protocol development
  • Centers of excellence
  • High public awareness
  • Rapid access to EMS
  • Prehospital notification, triage
  • Prehospital ECG, interventions
  • Confirmatory tests
  • Strong collaboration with specialists
  • Team and protocols in place in ED
  • Door to Drug/Groin - 30 Minutes or
  • Golden hour of trauma

6
But the Brain is not the Heart
  • Brain receives 20 of C.O. yet represents only 2
    TBW
  • Highly dependant upon continuous supply of oxygen
    and glucose
  • Minimal energy reserves
  • Compensation strategies limited

7
After the initial insult to the brain
  1. Nothing can be done and the injury is complete
  2. The injury develops over days but can not be
    stopped
  3. The injury evolves with multiple opportunities
    for intervention

8
Brain Ischemic Cascade
9
Acute Ischemic Stroke
10
Barriers to Stroke (Neurologic) Treatment
  • Slow response
  • Poor public education
  • EMS on-board but needs direction
  • ED response variable
  • Challenging diagnosis
  • Lack of
  • Physician integration / Neurology
  • Hospital commitment
  • Treatment issues
  • Labor intensive (?)
  • Narrow therapeutic windows
  • Concern of complications

11
Areas of Advancement
  • Epidemiology
  • Public education
  • EMS education and integration
  • Medical community education
  • Prevention
  • Acute management
  • Rehabilitation
  • Public policy health care systems development
  • Basic science research and funding
  • But clearly more data are needed

12
Rates for Vascular Events
  • Age-specific rates for stroke, myocardial
    infarction and sudden cardiac death combined, and
    acute peripheral vascular events

(Rothwell, Lancet, 200536629-36)
13
Contribution of Selected Risk Factors to Stroke
Incidence
Risk Factor RR Prevalence ()
  • Hypertension 3.0 5.0 25 56
  • Cardiac disease 2.0 4.0 10 20
  • Atrial fibrillation 5.0 18.0 1 2
  • Diabetes mellitus 1.5 3.0 4 8
  • Cigarette smoking 1.5 3.0 20 40
  • Heavy alcohol use 1.0 4.0 5 30

Adapted from Sacco. In Gorelick and Alter (eds).
Handbook of Neuroepidemiology. New York Marcel
Dekker, Inc 199487, with data from Feinberg.
Curr Opin Neurol. 1996946 Gorelick. Stroke.
199425222.
14
TIA Prediction of Secondary Risk
  • A six-point ABCD score
  • Age gt60 years1
  • Blood pressure systolic 140 mm Hg and/or
    diastolic 90 mm Hg 1
  • Clinical features unilateral weakness 2,
    speech disturbance without weakness 1,other
    0
  • Duration of symptoms (min) 60 2, 1059 1,
    10 0

(Rothwell, Lancet, 200536629-36)
15
General EM Community ViewACEP Survey on tPA Use
  • 1105 practicing EM Physicians responded to survey
  • 40 responded not likely to use tPA
  • 65 due to risk of ICH
  • 23 due to lack of efficacy
  • 12 due to both
  • Use of tPA associated with
  • Previous use
  • Female gender
  • Highest acceptable risk of ICH 4.3

(Brown, Ann Emer Med 20054656-60)
16
ECASS, NINDS ATLANTIS Pooled Analysis
(Lancet 2004 36376874)
17
Overall Safety of tPA in General Practice
Symptomatic Intracerebral Hemorrhage
(Graham, Stroke 2003 342487-50)
18
Given 8 of ED visits are for potentially
neurological conditions, what residency
programs have required neurology rotations
  1. 15
  2. 25
  3. 50
  4. 75
  5. gt90

19
Neurologic Education in US Emergency Medicine
Residencies
  • Survey of all US EM training programs
  • 78 response rate
  • 12 hours annually of neurologic didactic
    education
  • Required rotations
  • Neurology 17.4 (50 ICU based only)
  • Neurosurgery 15.2
  • Both 1
  • Neurology / neurosurgery / neuroradiology
    electives
  • Available in 32 programs
  • Rarely utilized

(Stettler, Acad Emer Med 2005 12909911)
20
Solution Education
  • Foundation for Education and Research in
    Neurological Emergencies
  • Fellowship training
  • One year stroke fellowship
  • Two year neurocritical care fellowship
  • Joint AHA-ACEP-SAEM-EMF Fellowship
  • 2005 Neurocritical Care
  • Neurology subspecialty
  • Open to emergency medicine

21
Solution Combine the Strengths
22
Solution Collaborative Education
  • 2005 1st National Stroke Conference
  • Sponsored by Canadian Stroke Consortium
    Canadian Stroke Network Canadian
    Association of Emergency Medicine Canadian
    Society of Internal Medicine
  • 150 emergency physicians, internists, and stroke
    neurologists
  • 2005 ILCOR consensus on science
  • 2006 Joint ACEP / AAN statement
  • 2006 Joint ACEM / SUHA statement

23
Solution Collaborative Research
  • EM essential element in recent NIH/NINDS/NHLBI
    initiatives
  • Specialized Program of Translational Research in
    Stroke (SPOTRIAS)
  • Neurological Emergencies Trialists Network
    (NET2)
  • Resuscitation Collaborative (ROC)

24
Solution Organized Stroke Care
  • 21 reduction in early mortality
  • 18 reduction in 12 month mortality
  • Decreased length of hospital stay
  • Decreased need for institutional care

(Ronning, Stroke 1998 2958-62) (Jorgensen,
Stroke 1994)
25
Solution Stroke Unit
  • Distinct facility staffed by physicians, nurses,
    and rehabilitation personnel or mobile stroke
    service with similar components
  • Monitoring capabilities providing close
    observation for neurological worsening or other
    complications
  • Regular communication and coordinated care
  • Neurologist or stroke specialist involvement
    improves outcome

(van der Walt, Med J Aust 2005 Feb
21182(4)160-3) Adams HP, Stroke
2003341056-1083) (Goldstein, Neurology
200361792796)
26
Primary Stroke Centers
  • Patient care areas
  • Acute stroke teams
  • Written care protocols
  • EMS participation
  • Emergency Department participation
  • Stroke unit
  • Neurosurgical services
  • Support services
  • Organizational support
  • Stroke center director
  • Neuroimaging
  • Laboratory
  • Outcome quality measures
  • CME

As of 11/05 186 JCAHO Approved PSC, 920 pending
(Brain Attack Coalition, JAMA 2000)
27
Stroke Systems
  • A stroke system should coordinate and promote
    patient access to the full range of activities
    and services associated with stroke prevention,
    treatment, and rehabilitation, including the
    following key components
  • Primordial and primary prevention
  • Community education
  • Regional integration of emergency medical
    services
  • Acute stroke treatment, including the hyperacute
    and emergency department phases
  • Subacute stroke treatment and secondary
    prevention
  • Rehabilitation
  • Continuous quality improvement (CQI) activities

(Schwamm etal, Circulation. 20051111078-1091)
28
It is Not Just About tPAPutting It All Into
Context
  • North East Melbourne Stroke Incidence Study
  • Of 306,631 people, there were 645 incident
    strokes
  • Extrapolated number saved from death or
    dependency for every 1,000 cases
  • 46 (95 CI 1769) with stroke unit management
  • 6 (95 CI 111) by using aspirin
  • 11 (95 CI 517) by using tPA at 3 hrs
  • 10 (95 CI 316) by using tPA at 6 hrs
  • Although tPA is the most potent intervention,
    management in stroke units has the greatest
    population benefit and should be a priority

(Stroke Unit Collaborative, 2002 Cochrane
Review) (Gilligan, Cerebrovasc Dis
200520239244)
29
Solution Provide Neurologic Expertise
  • On site
  • Phone consultation
  • Kansas City
  • Telemedicine
  • Reno NV
  • Bavaria Swabia
  • Massachusetts
  • UC San Diego
  • UT - Houston

(Wiborg, Stroke. 2003 342951-2957) (Schwamm,
Acad Emer Med 2004 1111931197)
30
Greater Cincinnati / Northern Kentucky Stroke
Team History
  • Conceived in 1978 and formed in 1982 as a
    collaboration between the Departments of
    Neurology and Emergency Medicine
  • Original goal was to Maximize stroke patient
    outcome by delivering evidenced-based effective,
    efficient and safe stroke care throughout
    pre-hospital and acute hospitalization to all
    stroke patients in the Tri-state region.

(Judy Spilker)
31
GC/NK Stroke Team Elements
  • Acute treatment physicians
  • Nurse coordinators
  • Neurosurgeons and neuroradiologists
  • Clinical fellows in neurology, emergency
    medicine, neurocritical care
  • Rehabilitation medicine physicians
  • Biostatistics / Grant support staff
  • Basic science researchers
  • EMS personnel

32
GC/NK Stroke TeamCommando Model
  • Multi-Disciplinary team
  • 3 Emergency physicians
  • 6 Vascular neurologists
  • 3 Neuro-interventionalists
  • 2 Neurosurgeons
  • 1 Neurointensivist
  • Hordes of nurses
  • 15 Local hospitals
  • 1 University
  • 3 Teaching
  • 11 Community
  • 10 Rural hospitals

t-PA treatments within 3 hours 110
patients/yr t-PA treatments within 2 hours 30
patients/yr 30 intra-arterial tPA treats per year
33
Stroke System Spoke and HubOntario Stroke Net
34
Governmental Support
  • Epidemiology
  • Coverdale Registry
  • Phase IV registry
  • SITS-ISTR / MOST
  • Governmental Support
  • JCAHO certification
  • 2005 DRG 559 Acute Ischemic Stroke with Use of
    Thrombolytic Agent with base rate 11,578 up
    from 4,000 to 6,000
  • STOP Stroke Act

35
  • Development Protocol and pathway development
  • Detection Early recognition
  • Dispatch Early EMS activation
  • Delivery Transport management
  • Door ED triage
  • Data ED evaluation management
  • Decision Neurology input, therapy selection
  • Drug Thrombolytic future agents
  • Disposition Admission or transfer

36
NINDS Symposium Recommendations
  • Door-to-MD 10 minutes
  • Door-to-Stroke 15 minutes
  • Team notification
  • Door-to-CT scan 25 minutes
  • Door-to-Drug 60 minutes
  • (80 compliance)
  • Door-to-Admission 3 hours

(NINDS Stroke Symposium 2003)
37
Emergency Medicine ? Janus (ianua) The Roman god
of gates and doors
ER Lobby Triage
38
Development Stroke Team
  • Systems and personnel in place
  • Stroke Team well known to all!
  • Treatment oriented
  • Team follows the 3 As
  • Affable
  • Available
  • Able

844-7687
39
Data Rapid ED Evaluation and the Paradigm of
Stroke Diagnosis
40
Data Collection and Preparation
  • Check glucose labs
  • Two large IV lines
  • Oxygen as needed
  • Cardiac monitor
  • Continuous pulse-ox
  • Stat non-contrast CT scan
  • Begin general management
  • Activate Stroke Team
  • Confirm onset
  • Perform neuro exam
  • Get real rt-PA
  • Prepare to mix
  • Have pharmacy alerted
  • Discuss with patient and family potential
    treatments

41
General Stroke Management
  • Cardiac monitor
  • Observe for ischemic changes or atrial
    fibrillation
  • Intravenous fluids 
  • Avoid D5W and excessive fluid administration
  • IV normal saline at 50 cc / hr unless otherwise
    required
  • NPO
  • Aspiration risk, avoid PO until swallowing
    assessed
  • Temperature
  • Avoid hyperthermia, PO/PR acetaminophen prn
  • Blood pressure
  • Function of fibrinolytic eligibility

42
Goal Directed Therapy for Cerebral Resuscitation
- AIS
  • Homeostasis in Acute Stroke
  • Glucose control
  • Tighter early control
  • Temperature control
  • Normothermia at a minimum
  • Hypothermia?
  • Optimal oxygenation
  • MRI infarct volumes reduced with hyperoxia
  • Optimal BP management

Glucose Mediated Proinflammatoryand Procoagulant
Effects
(Singhal Stroke. 200536797-802)
43
Physical Exam Challenges
  • Heterogeneity of stroke presentations
  • Many MDs poorly trained in neurologic
    examinations
  • Assessment scales viewed as cumbersome
  • No common language between physicians

44
CT Scanning and Interpretation
  • Neuro-imaging
  • 24 / 7 availability priority acquisition
  • CT staff on stroke pager
  • Open lines of communication
  • Priority interpretation with treatment
    considerations
  • An issue for EMS triage
  • CT in acute stroke
  • 31 with EIC in NINDS (not a/w ICH)
  • MRI
  • Sensitive (DWI) and can detect ICH (GRE)

(Patel, JAMA 20012862830-2830) (Nedeltchev,
Stroke 2003341230-1234)
45
Solution Improved Neuroimaging
Xenon CT
TCD
CTA
MRI
DW MRI
MRA
46
Solution Biomarkers of Stroke
  • Unlike myocardial infarction, no single biomarker
    is sufficiently robust
  • An integrated panel of biomarkers targeting
    different components of the ischemic cascade
    would provide better diagnostic accuracy

47
Potential Marker Targets
  • Glial markers
  • S100
  • Glial fibrillary acidic protein
  • Inflammatory mediators
  • MMP-9
  • VCAM
  • IL-6
  • Intracellular adhesion molecule, ICAM
  • Tumor necrosis factor
  • Neuronal cell adhesion molecule
  • IL-1 receptor antagonist
  • IL-1
  • IL-8
  • Monocyte chemoattractant protein-1
  • Vascular endothelial growth factor
  • Markers of thrombosis
  • vWF
  • Markers of cellular injury and myelin breakdown
  • Creatinine phosphokinase, brain band
  • Tissue factor
  • Myelin basic protein
  • Proteolipid protein
  • Malendialdehyde
  • Markers of apoptosis, growth factors, etc
  • Brain natriuretic peptide
  • Caspase 3
  • Calbindin-D
  • Heat shock protein 60
  • Cytochrome C

(Lynch, Stroke 2004)
48
Potential Stroke Applications
  • Assist in triage of patients to appropriate
    centers
  • Assist in the diagnosis of disease
  • Guiding treatment decisions and patient selection
  • Measuring treatment efficacy
  • Identifying patients at risk for complications
  • Providing prognosis
  • Selection of patients for intensified prevention
  • Development of new treatment strategies

49
Biomarker Panel Model for Stroke
  • Patients with potential stroke enrolled within 6o
    from symptom onset at two centers
  • Initial univariate analysis using BNP,
    Caspase-3, CRP, D-dimer MMP-9, and S100ß
  • Multivariate analysis created a model with CRP,
    D-dimer, S100ß using trichotomized output for
    diagnosis within 3 hours
  • Derivation PPV / NPV 100 100 66 pts
  • Validation PPV / NPV 72 90 54 pts

(Lynch and Jauch, 2005 ISC New Orleans )
50
Stroke Predictors vs Mimics
plt 0.0001
Caspase-3 D-Dimer RAGE Chimerin Secretagog
in MMP-9
p 0.0001
p 0.006
p 0.011
Overall Accuracy lt24h 91 Overall Accuracy lt6h
80.5
p 0.041
p 0.046
OR
0 1 2 3 4
5 6
(Montaner, 2005 European Stroke Conference,
Bologna)
51
BRAIN Study
  • Design
  • Industry sponsored (Biosite)
  • Multicenter prospective study of patients
    presenting with possible stroke
  • Sites
  • 16 U.S, 4 European
  • Subjects
  • Age-Matched Normals 839
  • Stroke Mimics 239
  • TIA 115
  • Ischemic Stroke 189
  • Intracranial Hemorrhage 119

52
Multimarker Approach (MMX)
  • Mathematical model incorporating
  • BNP, D-dimer, MMP-9, and S100

10
Two thresholds based on clinical setting
5.9
Optimal specificity (rule in)
5
1.3
Optimal sensitivity (screening)
0
53
MMX vs. Diagnosis
54
Stroke vs. Mimic Test Performance
Time Sensitivity Ischemic Stroke (MMX lt1.3) Sensitivity ICH (MMX lt1.3) Sensitivity All (MMX lt1.3) Specificity (MMX gt5.9)
0-6 88 (15/17) 86 (6/7) 88 (21/24) 90.2 (37/41)
6-12 93.4 (199/213) 90.7 (49/54) 92.9 (248/267) 91.7 (133/145)
12-24 92.4 (145/157) 96.7 (57/59) 93.5 (202/216) 89 (100/112)
55
Ongoing Studies Utilizing Markers
  • Prevention / Epidemiology
  • REGARDS
  • Acute treatment studies
  • ONO 2506 Stroke Trial
  • CLEAR Trial
  • IMS II, IMS III
  • ENOS
  • FAST (Novo 7)

56
Other Neurologic Conditions
  • Neurologic Emergencies
  • Trauma
  • Major TBI
  • Concussions
  • Child abuse
  • Neurovascular
  • ICH, SAH, TIA
  • Global ischemia
  • Status Epilepticus
  • Others
  • Infectious diseases
  • Prion, JCD
  • Meningitis
  • Degenerative diseases
  • Alzheimers
  • Parkinsons
  • Inflammatory diseases
  • Multiple sclerosis
  • Perioperative

57
Decision EP, Neurology, RadiologyDrug
tPA, Mechanical, OtherDisposition Stroke Unit,
ICU, Transfer
58
Current Treatment Decisions
  • No thrombolytics
  • Nothing
  • Aspirin
  • Death / nonfatal strokes reduced 11
  • Heparin
  • Intravenous rt-PA
  • Risk stratify although all subgroups benefited
    from thrombolytics in NINDS
  • Other investigational treatment
  • Intra-arterial thrombolysis
  • Low dose IV rt-PA followed by IA rt-PA
  • Embolectomy (MERCI)

59
The Future of Stroke Treatment
  • Increased public and medical community education
  • Regional stroke systems Tiered Stroke Centers
  • New diagnostic tools Neuroimaging, markers
  • Optimization of physiologic parameters
  • New thrombolytics ProUK, TNK, rPA, ANCROD
  • Combination agents Antiplatelets,
    neuroprotectives
  • Intra-arterial approaches IA, stents, angioplasty
  • Global cerebral protection Hypothermia, HBO
  • Surgical Hemicraniectomy, cell transplant
  • Other forms of stroke Novo 7, vasospasm
    treatments, surgery
  • Rehabilitation
  • Primary and secondary prevention!

60
Solution New Medical Treatments
  • Thrombolytics
  • TNK, rPA, desmotoplase, prourokinase
  • GP IIb/IIIa agents
  • Abciximab, eptifibatide
  • Antithrombotic agents Argatroban
  • Neuroprotective agents
  • Other (Albumin, ancrod)
  • Aggressive management
  • Glucose, temperature and BP control

61
New Intra-arterial Strategies
62
Endovascular and Surgical Procedures
  • Aneurysms
  • Coiling
  • Glue (AVMs)
  • Embolization
  • Aneurysm clipping
  • Hemorrhage
  • Stereotactic aspiration
  • Stroke
  • Hemicraniectomy
  • Intracranial stenting
  • Carotid stenting
  • Carotid endarterectomy

63
Other Developing Strategies
Hyperbaric Oxygen Therapy
Hypothermia
EMS Intervention FAST-Mag
64
Post-Treatment Care
65
Early Stroke Care
  • Begin Acute Stroke Pathway
  • ICU admission now
  • 24 hrs for tPA
  • Q 15 X 6 hours, Q 1ox18 hours
  • Facilitate medical or surgical measures to
    improve outcome after stroke
  • Optimize blood pressure, glucose, temp
  • Begin to prevent subacute complications
  • Plan for long-term therapies to prevent recurrent
    stroke
  • Start efforts to restore neurological function

(Adams Stroke. 2003341056-1083)
66
Intracerebral Hemorrhage
19 yo with ephedra induced ICH
67
Emergent Evaluation
  • Immediate stabilization (ABCs)
  • Baseline labs
  • CBC, coags, electrolytes
  • Neuroimaging
  • CT remains gold standard
  • Identify ICH and complications (hydrocephalus,
    herniation)
  • MRI / MRA
  • Evaluate for structural abnormalities (AVM,
    aneurysms)
  • Angiography
  • Identify vascular issues preoperatively in occult
    ICH

68
Goal Directed Therapy for Cerebral Resuscitation
- ICH
  • Glucose control
  • Tighter control with better outcomes
  • Temperature control
  • Normothermia at a minimum
  • Coagulation homeostasis
  • Vit K (10mg) / FFP (15ml/kg)
  • Every 30 delay decreases odds of normalization
    within 24 hrs
  • Fluid management
  • Optimal BP management

http//www.stopstroke.org
(Steiner Stroke 200637256-262) Goldstein Stroke
200637151-155)
69
ICH Prognosis
  • ICH volume ABC/2
  • Worse prognosis
  • Volume gt 60 cm3 and GCS lt 9
  • 91 dead at 30 days
  • Patients with volume gt30 cm3 1 / 71 independent
    at 30 days
  • Intraventricular extension, age
  • Better
  • Volume lt 30 cm3 and GCS 9 or higher
  • 19 dead at 30 days

(Broderick, Stroke 1997)
70
General Medical Management
  • ABCs
  • Blood pressure control
  • ICP management (goal ICP lt 20 mm Hg CPP gt 70 mm
    Hg)
  • Hyperventilation
  • Osmotherapy
  • No role for glycerol, corticosteroids,
    hemodilution
  • Other
  • Prevention of hyperthermia
  • Fluid management (CVP at 5-12 mm Hg)
  • Modifications for age, comorbidities, size,
    severity, location
  • Seizure control
  • Find somebody to take the patient

71
Surgical Evacuation
  • Largest surgical trial (1033 patients, 27
    countries, 8 years)
  • Surgery within 96 hours from onset vs medical
    management
  • Outcome
  • Primary Favorable outcome at 6 months
  • Secondary Mortality

(Mendelow, A. Lancet, 2005365387-397)
72
Surgical Evacuation
  • No difference in
  • Favorable outcome
  • (26 vs. 24, OR 2.3)
  • Mortality (36 vs 37, OR 1.2)
  • Mean total 6 month cost (18452 vs 20513)
  • Unanswered questions
  • Timing, location, methods

Mortality curves
(Mendelow, A. Lancet, 2005365387-397)
73
Hemostatic Therapy
  • Few late studies (mostly in SAH)
  • Aminocaproic acid
  • Tranexamic acid
  • Ultra-early studies
  • rFVIIa
  • Pilot (n48)
  • F7ICH-1371 (n399)
  • Within 3 hrs onset
  • Phase III (n675) ongoing

(Mayer, Stroke 20053674-79) (Mayer, NEJM
2005352777-785)
74
Factor rVIIa Treatment
P0.07
P0.05
P0.02
75
Factor rVIIa Treatment
  • rFVIIa limits ICH growth, reduces mortality, and
    improves functional outcomes
  • A small increase in the frequency of
    thromboembolic adverse events occurs with
    treatment (2 vs 7, p0.12)

(Mayer NEJM 2005352777-785)
76
Potential Future Tools in ICH
  • Medical therapies
  • Optimizing blood pressure (ATACH)
  • Tight glycemic control (THIS)
  • Early anticoagulation reversal
  • Neuroprotectives (CHANT, Fast-MAG, hypothermia)
  • Ultra-early hemostatic therapy (rFVIIa)
  • Surgery
  • Surgical patient selection and new approaches
  • Stereotactic evacuation with tPA (MISTIE)
  • Intraventricular evacuation with fibrinolysis
    (ITT, DITCH)

77
Subarachnoid Hemorrhage
78
Subarachnoid HemorrhageDiagnosis and Prognosis
  • Improved bilirubin/xanthochromia detection as a
    better diagnostic tool
  • Serum S100b levels correlated with early
    neurologic deficit and outcome lt 20
    ng/ml favorable outcome gt 100 ng/ml severely
    disabled or died
  • BOXes potent vasoconstrictor and present in CSF
    in vasospam

(Morgan, J Neurosurg 20041011026-9) (Pyne, J
Cereb Blood Flow Metab 2005) (Persson, Acta Neuro
1988) (Weisman, Acta Neurochir 1997)
79
Goal Directed Therapy for Cerebral Resuscitation
- SAH
  • Glucose control
  • Tighter control with better outcomes
  • Temperature control
  • Normothermia at a minimum
  • Hypothermia local / global
  • Inflammation control
  • NO pathways
  • Optimal BP management

(Frontera Stroke 2006 37199-203) (Provencio
Semin Neurology 2005 25435-444)
80
SAH Treatment
  • Endovascular strategies increasingly effective
    with better long-term outcomes
  • Concentrating care at specialized high volume
    centers may improve outcomes
  • Keys to future advances
  • Earlier diagnosis
  • Initiation of homeostasis
  • Initiation of modulators of inflammation
  • Emergent referral for definitive correction

(Cross, I 200399810817) (ISAT Lancet
2002360126774)
81
In the future, which physician will have the
greatest opportunity to alter outcome in acute
brain injury
  1. Emergency physician
  2. Neurologist
  3. Neurosurgeon
  4. Physical medicine and rehabilitation
  5. All the above

82
Conclusion
  • It is a great time to be an Emergency Medicine
    physician
  • It will be the EM physician who will play a key
    role in cerebrovascular resuscitation
  • Maximizing our potential will require
  • Increased education
  • Subspecialty support
  • Institutional commitment
  • Collaborative research

83
(No Transcript)
84
Community Education TLL Temple Foundation Stroke
Project
  • Aggressive multilevel stroke education program in
    rural Texas led to
  • Decreased time to arrival (in both
    groups) (Median 8.4 to 3.7 hours)
  • Increased treatment in eligible patients (14
    to 52 vs. 7 to 6)
  • Increased rt-PA utilization overall (1.4 to
    5.8 vs 0.5 to 0.55 in control community)

(Morgenstern, Stroke 2002 Jan33(1)160-6)
85
Stroke System Rural SystemsWashoe Health System
  • Rural Nevada System
  • 25 hospitals, one team
  • Teleradiology available
  • Telemedicine at 3
  • 9 treatment rate
  • 20 transferred to hub for ICU care

86
JCAHO Standardized Stroke Measures
  1. Deep vein thrombosis (DVT) prophylaxis
  2. Atrial fibrillation anticoagulation therapy
  3. Tissue plasminogen activator (t-PA) considered
  4. Antithrombotic medication within 48 hours
  5. Lipid profile during hospitalization
  6. Screen for dysphagia
  7. Stroke education
  8. Smoking cessation
  9. Discharge on antithrombotics
  10. Plan for rehabilitation

87
Recurrent Stroke and TIA after TIA
(Johnston Neurology 200360280-285)
88
Histogram of TIA Values
89
rt-PA 3 Hour Meta-Analysis
(Saver, BMJ 2002 324727-729)
90
Biomarkers and the Neurovascular Unit
PREDICT NEUROLOGICAL OUTCOME (parenchyma
information) PREDICT HEMORRHAGIC
COMPLICATIONS (BBB information) PREDICT
RECANALIZATION, REPERFUSION AND
REOCCLUSION (vessel information)
(Lo, Broderick and Moskowitz. Stroke 2004)
91
Areas of Advancement
  • Acute management
  • Development of pathways, protocols
  • Stroke teams, units
  • Improved diagnosis
  • Improved general management
  • Review of tPA data
  • Additional methods of recanalizaton

92
More than Just Proteins for Diagnosis
  • Proteomics, genomics, and genetics will aid in
    diagnosis and treatment selection
  • Genes are quickly and uniquely regulated in
    setting on neuronal injury
  • Apo E modulates response to rtPA (ApoE2 OR 6.4 of
    favorable outcome with rtPA)

(Tang, Ann Neuro 2001) (Broderick, Ann Neuro
2001) (Clark, Front Biocsci 2002)
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