Title: Ischemic Anterior Circulation Stroke Edward C. Jauch, MD, MS Assistant Professor Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati, OH and Greater Cincinnati/Northern Kentucky Stroke Team
1Ischemic Anterior Circulation StrokeEdward C.
Jauch, MD, MSAssistant ProfessorDepartment of
Emergency MedicineUniversity of Cincinnati
College of MedicineCincinnati, OHandGreater
Cincinnati/Northern Kentucky Stroke Team
2Lecture Goals
- Review Emergency Department evaluation of acute
ischemic stroke - Identify symptoms of anterior circulation stroke
- Identify issues specific to thrombolytic therapy
in acute stroke - Identify treatment options for acute ischemic
stroke
Introduction
361 year old male, with acute aphasia, right
facial droop, and right sided weakness
- 1230 Sudden onset while working in yard
- 1245 Family calls 911
- 1305 Advanced squad evaluates and
rapidly transports - 1315 Squad notifies receiving hospital
of possible stroke
patient
Case
461 year old male with possible stroke arrives at
Our Lady of Faint Hope
- 1330 ED triage and physician evaluation
- 1345 Stroke Team responds
- 1400 CT scan performed
- 1415 Discuss with family and PMD
- 1420 Labs back gluc 97 BP remains 150/70s
Case
5Neurologic ExaminationNIH Stroke Scale
Case
661 yo male with possible stroke
- 1420 CT reading No hemorrhage or early
ischemia - 1425 Checklist done No exclusion
criteria met - 1430 Decision time
Case
7Impact of Stroke
- 3rd leading cause of death in the U.S.
- A leading cause of adult disability
- 600,000 new strokes per year in U.S.
- 85 are ischemic
Introduction
8Death Rates from Stroke
(Dept Health and Human Services)
Epidemiology
9Stroke Outcomes
- In the 4.5 million US stroke survivors
- 10 Recover almost completely
- 25 Recover with minor impairments
- 40 Experience moderate to severe
impairments requiring special care - 10 Require care in a nursing home or other
long-term care facility - 15 Die shortly after the stroke
(NSA, 2001)
Outcomes
10Stroke Outcomes
- Medical morbidity associated with stroke
- 30 Develop pneumonia within first month
- 10 Risk of recurrent stroke per year
- 10 Deaths post-stroke from pulmonary
embolisms -
- Other morbidity from stroke
- 23 Develop multi-infarct dementia
- 70 Develop depression (27 major)
- 40 Depression common among care-givers
High end of estimates
Outcomes
11Stroke Risk Factors
- Modifiable risk factors
- High blood pressure
- Cigarette smoking
- Transient ischemic attacks
- Heart disease
- Diabetes mellitus
- Hypercoagulopathy
- Carotid stenosis
- Other
- Unmodifiable risk factors
- Age
- Gender
- Race
- Prior stroke
- Family History
- Other possible risk factors
- Sickle cell disease
- Apolipoproteins
- Others
Epidemiology
12Influence of Initial Medical Contacton Arrival
Times to the E.D.
(Barsan, Arch Int Med, 1993)
Epidemiology
13Detection
- What are Signs Symptoms?
- 43 general public didnt know any
- 39 of acute stroke patients didnt know any
- What are Risk Factors?
- 32 general public didnt know any
- 43 of acute stroke patients didnt know any
(Pancioli JAMA 1998 Kothari Stroke 1997)
14Where Are We Today?
- Poorly informed
- Too slow
- Too late
- Ill prepared
- Fatalistic
Epidemiology
15Forces of Change
- Public expectations
- Aware of Draino for the Braino
- Nihilistic attitude of stroke changing
- Medical - legal pressures
- Managed care cost concerns
- New treatments of stroke on horizon
- Change in treating physicians perceptions of
risk
Epidemiology
16Organized Stroke Care Saves Lives
- 21 reduction in early mortality
- 18 reduction in 12 month mortality
- Decreased length of hospital stay
- Decreased need for institutional care
(Jorgensen, Stroke 1994)
Epidemiology
17Patient Aversion to Various Stroke Outcomes
Aversion
(Solomon, Stroke 1994)
Epidemiology
18Tissue-Plasminogen Activator inAcute Ischemic
Stroke
- Double-blinded, randomized
- Placebo controlled
- 0.9 mg / kg IVP dose
- 624 patients
- Treated within 3 hours
- 1/2 within 90 minutes
- 1/2 within 91-180 minutes
Management
19Benefits of Thrombolyticsin the NINDS Trial
For every 16 patients
No/Minimal Moderate
Severe Dead
20Relationship of Time to Thrombolytic
Treatment Odds Ratio of Favorable Outcome
Time is Brain!
Odds Ratio for Favorable Outcome at 3 Months
Benefit for rt-PA No Benefit for rt-PA
Minutes from Stroke Onset to Start of Treatment
Management
21Symptomatic Hemorrhages by CT Findings in NINDS
Trial
Percent of Patients that Developed Symptomatic
Hemorrhages
Edema or Mass Effect Seen on Initial CT
(Broderick, Stroke 1997)
22Symptomatic Hemorrhages by Baseline NIHSS in the
NINDS Trial
Percentage of t-PA Patients with Symptomatic ICH
(Broderick, Stroke 1997)
23Cost Effectiveness for rt-PA in Acute Ischemic
Stroke
- rt-PA placebo p value
- LOS 10.9 12.4 0.02
- Discharge home 48 36 0.002
- With rt-PA, considering 1,000 eligible patients
- Hospitalization costs 1.7 million more
- Rehabilitation costs 1.4 million less
- Nursing home costs 4.8 million less
- 564 quality-adjusted life-years saved
(Fagan, Neurology 1998)
Epidemiology
24STARS Study
- Prospective Phase IV study mandated by FDA
- Multicenter (24 academic, 33 community)
- NINDS protocol used for 389 patients
- Median times Onset to treatment 2.7
hrs Arrival to treatment 1.6 hrs Less than 4
treated in under 90 mins - Median NIHSS 13 (14 mean)
(Albers, JAMA 2000)
Management
25STARS Study
- Results Outcome
- Favorable outcome 35 (mR?1)
- Functionally independent 43 (mR?2)
- 30 day mortality rate 13
- Results Complications
- Symptomatic ICH 3.3
- Within 3 days
- Fatal ICH 1.8
(Albers, JAMA 2000)
Management
26STARS Study
- Predictors of favorable outcome
- Baseline NIHSS lt 10
- Absence of significant CT abnormalities
- Age lt 85 years
- Lower mean arterial pressure
- Predictors of lack of response
- NIHSS (22 decrease in OR per 5 points)
- NIHSS gt 10 75 decrease in OR
- Significant CT findings 87 decrease in OR
- Increased mean arterial pressure 19 decrease in
OR
(Albers, JAMA 2000)
Management
27Cleveland Area Experience
- Historical prospective cohort study
- Conducted July 1997 through June 1998
- Multicenter 29 hospitals (academic
and community) - No coordination or fixed protocol (NINDS
protocol assumed) - 3948 patients reviewed
(Katzen, JAMA 2000)
Management
28Cleveland Area Experience
- Results
- 3984 AIS patients admitted to 29 hospitals in 1
yr - 17 admitted within 3 hours of stroke onset
- 1.8 received t-PA at 16 hospitals (0 - 10.2
of stroke patients) - Of the top 4 hospitals in Cleveland, utilization
ranged from 0-28 within 3 hour window
(Katzen, JAMA 2000)
Management
29Cleveland Area Experience
- Results Complications in tPA patients
- Total ICH rate 22
- Symptomatic ICH 15.7
- Fatal ICH 8.6
- Results Mortality rate
- tPA patients 15.7
- Patients in 3 hours ø tPA 7.2
- All patients ø tPA 5.1
(Katzen, JAMA 2000)
Management
30Cleveland Area Experience
- Results Protocol violations
- Total NINDS violations 50
- Antiplatelets / anticoagulants 37.1
- Beyond 3 hours 12.9 (3.15-6.25 hrs)
- Risk of complications not associated with
protocol violations (p0.74)
(Katzen, JAMA 2000)
Management
31How to Evaluate and Treat Acute Ischemic Stroke
in 2000
Evaluation
32Acute Myocardial Infarction
- This paradigm has shifted
- Chest pain / SOB / dysrhythmia
- Rapid access to EMS
- Prehospital identification and call
- Prehospital ECG
- Team and protocols in place in ED
- Door to Drug - 30 Minutes
- What is the mortality and morbidity?
Evaluation
332000 American Stroke AssociationNew Guidelines
- EMS systems should implement a stroke protocol
- Potential fibrinolytic candidates should be taken
to hospitals capable of providing acute stroke
care - E.D. AIS triage should be similar to AMI
- Intravenous fibrinolysis for AIS is Class I
- Intra-arterial fibrinolysis for AIS is Class IIb
(ASA, Circulation 2000)
Evaluation
34Stroke Chain of Survival Recovery
- Detection Early recognition
- Dispatch Early EMS activation
- Delivery Transport management
- Door ED triage
- Data ED evaluation management
- Decision Specific therapies
- Drug Thrombolytic future agents
Evaluation
35NIH 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
Evaluation
36Detection Stroke Public Awareness
Evaluation
37Dispatch Call 911Delivery Transport
Management
- Priority dispatch
- ABCs
- Time of onset
- Neurological evaluation / Prehospital stroke
scale - Check glucose
- Stroke recognition
- Early hospital notification
- Rapid Transport
Evaluation
38Door Emergent TriageData ED Evaluation
Evaluation
39Preparation
- Check glucose
- Two large IV lines
- Oxygen as needed
- Cardiac monitor
- Continuous pulse-ox
- Non-contrast CT scan
- ECG
- CXR
- Perform the NIH stroke scale
- Get rt-PA
- Prepare to mix
- Have pharmacy alerted
- Make sure family is available
- Contact primary care provider
Evaluation
40Preparation
- Systems and personnel need to be in place
- Know your Stroke Team before you need them!
Evaluation
41General Stroke Management
- Oxygen
- Use to correct hypoxia
- Suggestion it may hurt one year survival 69
3L NC vs 73 control - Glucose
- Maintain euglycemia
- Treat glucose lt 50 with D50
- Treat glucose gt 300 mg/dl with insulin
(Rønning, Stroke 1999)
Evaluation
42General 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 is great, avoid oral intake until
swallowing assessed - Temperature
- Avoid hyperthermia, PO/PR acetaminophen prn
Evaluation
43The True Time of Onset
- Multiple sources
- How normal were they?
- Who saw them this morning?
- Clearly no symptoms?
- Times of reference
- The time the basketball game started
Evaluation
44Neurologic ExaminationNIH Stroke Scale
- Value of the NIHSS
- Correlates with size of stroke and prognosis
- Strokes with NIHSS lt 4 do well and are not
typically thrombolytic candidates - Strokes with NIHSS gt 20 are large with extremely
poor prognosis and fair response to IV
thrombolytics
Evaluation
45Middle Cerebral ArteryStroke Syndromes
- Dominant hemisphere
- Contralateral hemiparesis arm, face gt leg
- Contralateral sensory loss
- Contralateral homonymous hemianopia Ipsilateral
eye deviation - Brocas and Wernickes aphasias
- Non-dominant hemisphere
- Contralateral hemiparesis arm, face gt leg
- Contralateral sensory loss with extinction
- Contralateral homonymous hemianopia Ipsilateral
eye deviation - Dysarthria without aphasia
- Ipsilateral hemineglect, inattention, extinction
on double stimulation
Evaluation
46Anterior and Posterior Cerebral Arteries Stroke
Syndromes
- Anterior Cerebral Artery
- Contralateral hemiparesis leg gt arm, face
- Contralateral sensory loss
- Change in personality, speech perserveration
- Bilateral occlusions produce paraplegia,
anarthria, akinetic mutism - Posterior Cerebral Artery
- Contralateral hemianopia (patients frequently
unaware) - Brain stem findings (varied)
- Bilateral occlusions produce cortical blindness
Evaluation
47Early CT Changes in Ischemic Stroke
- Loss of insular ribbon
- Loss of gray-white interface
- Loss of sulci
- Acute hypodensity
- Mass effect
- Dense MCA sign
Relative contraindication
Evaluation
48ConsiderationsWho will it and wont it help
- Factors associated with worse outcomes
- Increased patient age
- History of diabetes mellitus
- Increased time from onset
- Increased blood pressure
- Increased stroke severity
- Baseline CT findings of stroke
- All subgroups (age, race, gender, co-morbid
illnesses, and stroke location and size)
benefited from thrombolytics compared to placebo
in the NINDS trial
Evaluation
49Factors Associated with Increased Risk of ICH
- Treatment initiated gt 3 hours
- Increased thrombolytic dose
- Elevated blood pressure
- NIHSS gt 20
- Acute hypodensity or mass effect on baseline CT
Evaluation
50Differential Diagnosis
- Intracerebral hemorrhage
- Hypoglycemia / Hyperglycemia
- Seizure
- Migraine headache
- Hypertensive crisis
- Epidural / subdural
- Tumor
- Meningitis / Encephalitis / Abscess
Evaluation
51Stroke Diagnosis - TIA
- TIA definition an arbitrary definition from
1970s - TIAs lasting longer than several minutes can
produce focal defects on neuroimaging - Median duration 14 mins / 8 mins
- If symptoms persist more than 1 hour, only 14
resolved by 24 hours - NINDS placebo group only had 2 improvement to
baseline at 24 hours
(CSOTIA)
Evaluation
52Exclusions to Thrombolytics
- Stroke or head trauma in 3 mos
- Major surgery within 14 days
- Any history of intracranial hemorrhage
- SBP gt 185 mm Hg
- DBP gt 110 mm Hg
- Rapidly improving or minor symptoms
- Symptoms suggestive of subarachnoid hemorrhage
- Glucose lt 50 or gt 400 mg/dl
- GI hemorrhage within 21 days
- Urinary tract hemorrhage within 21 days
- Arterial puncture at non-compressible site past 7
days - Seizures at the onset of stroke
- Patients taking oral anticoagulants
- Heparin within 48 hours AND an elevated PTT
- PT gt15 sec
- Platelet count lt100 X 109/L
Evaluation
53Exclusions to Thrombolytics
- Patients were also excluded if aggressive
measures were required to lower the blood
pressure to within specified limits
Evaluation
54Blood Pressure Management
- Gentle management if thrombolytic
candidate SBP gt 180 mm Hg DBP gt 110 mm Hg - Choices
- Labetalol 10 - 20 mg IV
- Enalapril 1.25 mg IV
- Nitropaste 1 to chest wall
- No nipride or nitroglycerin gtts
Evaluation
55Blood Pressure Management
- Management in non-thrombolytic candidates only
if SBP gt 220 mm Hg DBP gt 120 mm
Hg MAP gt 130 mm Hg - Also consider BP management in
- Acute myocardial infarction
- Aortic dissection
- True hypertensive encephalopathy
- Severe left ventricular failure
Evaluation
56What are the Options?
- No thrombolytics
- Nothing
- Aspirin
- Heparin
- Intravenous rt-PA Only approved therapy for
acute stroke - Other
- Intra-arterial thrombolysis
- Low dose IV rt-PA followed by IA rt-PA
- Investigation procedure
Treatment
57Stroke Treatment Aspirin / Heparinoids
- Aspirin
- Two large trials
- International Stroke Trial (IST)
- Chinese Acute Stroke Trial (CAST)
- Death / nonfatal strokes reduced 11
- If not a thrombolytic candidate, give within
first 24 hrs - Heparin
- Two important trials
- International Stroke Trial (IST)
- TOAST (Trial of ORG 10172)
- No net stroke benefit
Treatment
58rt-PA Dosing
- 0.9 mg/kg (max 90 mg)
- 10 bolus (over 1 minute)
- Remainder as a 1 hour infusion
- Have the rt-PA in the Emergency Department, not
the Pharmacy!
Treatment
59Post-Treatment Care
Treatment
60Patient Monitoring
- ICU admission (24 hours)
- Neuro checks
- Q 15 minute X 6 hours
- Q 1 hour X 18 hours
- BP checks
- Call on the FIRST abnormal reading!
- Do not hesitate to use a drip
- Watch for bleeding
Treatment
61Contingency Plan - ICH Orders
- STAT Repeat CT
- STAT Labs
- (Fibrinogen, CBC, PT/PTT)
- Type and screen
- Cryoprecipitate / Platelets
- Neurosurgical consult
Treatment
62Blood Pressure ManagementAfter Thrombolytics
- SBP 180 - 230 or DBP 105-120 mm Hg
- Labetalol 10 mg IV, may repeat / double to 150 mg
max - Labetalol drip 2-8 mg / min
- SBP gt 230 or DBP 121 - 140 mm Hg
- Above
- Sodium nitroprusside
- DBP gt 140 mm Hg
- Sodium nitroprusside (0.5 µg/kg per minute)
- May consider enalapril in patients with CHF,
asthma, abnormal cardiac conduction
Treatment
63Post-treatment Issues
- Management of seizures
- Management of increased ICP
- Risk factor identification and modification
- Swallowing assessment
- Early rehabilitation
Treatment
64The Future of Acute Stroke Treatment
- Establishment of tiered Stroke Centers
- New diagnostic tools Neuroimaging, markers
- Thrombolytics ProUK, TNK, rPA, ANCROD
- Intra-arterial approaches IA, stents,
angioplasty - Combination agents Antiplatelets, LMWH,
neuroprotectives - Cerebral protection Hypothermia, HBO
- Surgical Hemicraniectomy
- fibrinogenolytic
Future
65Primary Stroke Center Proposal
- 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
Individualized by institution Within 2 hours
(Brain Attack Coalition, JAMA 2000)
Future
66Intra-arterial Thrombolysis
Future
67Intra-Arterial Thrombolytic Efficacy vs.Time of
Delivery
EMS
GC/NK
PROACT
Control
(Ernst, Stroke 2000)
Future
6861 yo male with acute strokeThe Decision to
Treat
- 1435 IV rt-PA given. 0.9 mg/kg total 10
bolus - 9 mg 90 over 1 hr - 81 mg - 1545 Patient goes to ICU
- Report personally given to ICU staff
- 1550 Pathway actions begin
- (HOB, BP, aspiration precautions, carotid
ultrasound)
Case
6961 year old male s/p rt-PA 24 Hour Follow-up
- Initial NIHSS 10
- 24 hr NIHSS 3
- Mild facial palsy
- Right arm drift
- Mild dysarthria
- Repeat CT shows areas of infarct
Case
7061 year old male s/p t-PAHospital Course
- Carotid U/S shows 60 -80 stenosis left ICA
- Speech recommends swallowing II diet and daily
checks - Physical therapy ongoing
- CEA performed day 4
- Patient discharged day 7
Case
71Conclusions
- Acute stroke is an emergency
- Multidisciplinary systems must be in place in
every institution - Strict adherence to protocols minimizes
complications - Acute stroke treatment is and will remain the
responsibility of the Emergency Physician
Conclusion