THE INTERNET STROKE CENTER

PRESENTATIONS AND DISCUSSIONS ON STROKE MANAGEMENT

The Golden Hour of Acute Ischemic Stroke

Dr. Edward C. Jauch Department of Emergency Medicine University of Cincinnati College of Medicine Greater Cincinnati / Northern Kentucky Stroke Team

TABLE OF CONTENTS
A Look at Current Stroke Treatment Whats Changed in 2000? What Has Not Changed? Acute Stroke - Where are we Today? Models for the Golden Hour Trauma - Example Acute Myocardial Infarction - Example Forces of Change Organized Stroke Care Saves Lives Cost Eectiveness for rt-PA in Acute Ischemic Stroke Treatment Guidelines & Recommendations - Part I NIH National Symposium Recommendations Stroke Chain of Survival & Recovery Dispatch & Delivery: Transport & Management Cincinnati Pre-Hospital Stroke Scale NIH Stroke Scale
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Preparation American Heart Association Recommendations True Time of Onset Stroke Risk Factors Treatment Guidelines & Recommendations - Part II Early CT Changes in Ischemic Stroke Dierential Diagnosis What are the Options? Treatment Based on CT Findings Exclusions to Thrombolytics Pretreatment BP Treatment Treatment Considerations: Who Will Bene t from rt-PA? Factors Associated with Increased Risk of ICH Treatment Guidelines & Recommendations - Part III Symptomatic Hemorrhages by NIH Stroke Scale in NINDS Trial rt-PA Dosing Intra-arterial Thrombolytic Ecacy vs. Time of Delivery Stroke Treatment - Aspirin Stroke Treatment - Heparinoids Post-Treatment Guidelines & Recommendations Post Treatment Care - Antihypertensive Therapy ICH Contingency Plan Management of Seizures Rehabilitation What do you need to treat? Case Study

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History, Timeline, and Initial CT Findings 24 Hour Follow-up References

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A Look at Current Stroke Treatment

Whats Changed in 2000?
EMS systems should implement a prehospital stroke protocol to evaluate and rapidly identify patients who may bene t from brinolytic therapy, similar to the protocol for chest pain patients (Class IIb). Patients who may be candidates for brinolytic therapy should be transported to hospitals identi ed as capable of providing acute stroke care, including 24-hours availability of CT scan and interpretation. (Class IIb). Stroke presenting with 3 hours should be triaged on an emergent basis with urgency similar to acute ST-elevation myocardial infarction. Intravenous brinolysis for acute ischemic stroke Class I IV - t-PA within 3 hours of onset Class Indeterminate IV - t-PA between 3 and 6 hours of onset Intra-arterial brinolysis Class IIb IA prourokinase within 3 to 6 hours after symptom onset
Source: ASA, Circulation, 2000

What Has Not Changed?

Impact of Stroke 3rd leading cause of death in the U.S. Leading cause of adult disability Over 700,000 new stroke cases per year in U.S. with 150,000 stroke deaths per year 85% are ischemic Less than 25% of eligible thrombolytic candidates receiving therapy

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Acute Stroke - Where are we Today?

Where are we today? Public poorly informed Response time too slow Presentation too late Hospitals ill prepared Fatalistic

Models for the Golden Hour

Trauma Golden hour for intervention Centralized trauma center system, certi ed by the ACS Acute myocardial infarction Similar door-drug/groin benchmarks for reperfusion Decentralized system

Trauma - Example
Stab wound to the abdomen Very rapid EMS activation and transport Not exactly a dicult diagnosis Lots of communication Big teams Detailed protocols The Golden Hour What is the mortality and morbidity? - Low

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Acute Myocardial Infarction - Example

The paradigm has shifted Chest pain - patients know to call 911 Rapid access to EMS Pre-hospital identi cation and call Pre-hospital ECG Team, protocols, drugs in the ED Door to Drug in 30 Minutes What is the mortality and morbidity? - Low.

Forces 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

Organized 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
Source: Jorgenson, Stroke, 1994

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Cost Eectiveness for rt-PA in Acute Ischemic Stroke

rt-PA LOS Discharge Home 10.9 48% placebo 12.4 36% p value 0.02 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
Source: Fagan, Neurology 1998

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Treatment Guidelines & Recommendations - Part I

NIH National Symposium Recommendations
Door-to-MD: < 10 minutes Door-to-Neurologic Expertise: < 15 minutes Door-to-CT scan: < 25 minutes Door-to-CT Interpretation: < 45 minutes Door-to-Drug: (80% compliance) < 60 minutes Door-to-Admission: < 3 hours Notes: At this National Symposium, experts developed in-hospital time intervals to allow the stroke patient to be treated and evaluated in a expedient manner. These recommendations include: Emergency department arrival to initial physician evaluation: 10 minutes Emergency department arrival to Stroke Team Noti cation: 15 minutes Emergency department arrival to CT Scan initiation: 25 minutes And they recommended that 80% of eligible stroke patients presenting to the emergency department should be treated with tPA within 60 minutes.

Stroke Chain of Survival & Recovery

Detection: Early recognition Dispatch: Early EMS activation Delivery: Transport & management Door: ED triage Data: ED evaluation & management Decision: Speci c therapies Drug: Thrombolytic & future agents

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Dispatch & Delivery: Transport & Management

ABCs Stroke recognition Establish time of onset / his Perform neurological evaluation Check glucose Early hospital noti cation Rapid transport

Cincinnati Pre-Hospital Stroke Scale

Facial Droop Normal: Both sides of face move equally Abnormal: One side of face does not move at all Arm Drift Normal: Both arms move equally or not at all Abnormal: One arm drifts compared to the other Speech Normal: Patient uses correct words without slurring Abnormal: Slurred or inappropriate words or mute

NIH Stroke Scale

Item 1a 1b 1c 2 3 4 5 6 7 8 9 10 11 12 13 Description Level of Consciousness LOC Questions LOC Commands Best Gaze Best Visual Facial Palsy Motor Arm Left Motor Arm Right Motor Leg Left Motor Leg Right Limb Ataxia Sensory Neglect Dysarthria Best Language Range 03 02 02 02 03 03 04 04 04 04 02 02 02 02 03

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Preparation
Know your stroke team before you need them Check glucose Two large IV lines Oxygen as needed Cardiac monitor Continuous pulse-ox Stat non-contrast CT scan ECG CXR Get rt-PA > Prepare to mix > Have pharmacy alerted Discuss options with patient and family Contact primary care provider

American Heart Association Recommendations

Oxygen Use to correct hypoxia Suggestion that supernormal levels may hurt > one year survival 69% 3L NC vs 73% control Glucose Maintain euglycemia Treat glucose > 300 mg/dl with insulin
Source: Rnning, Stroke 1999

True Time of Onset

How normal were they? What are they like at baseline? Who saw them last? Clearly no symptoms? Times of reference Television The time the basketball game started
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Stroke Risk Factors

Modi able risk factors High blood pressure Cigarette smoking Transient ischemic attacks Heart disease Diabetes mellitus Hypercoagulopathy Carotid stenosis Other Non-modi able risk factors Age Gender Race Prior stroke Heredity

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Treatment Guidelines & Recommendations - Part II

Early CT Changes in Ischemic Stroke
Loss of insular ribbon Loss of gray-white interface Loss of sulci Acute hypo density Mass eect Dense MCA sign

Dierential Diagnosis
Intracerebral hemorrhage Hypoglycemia / Hyperglycemia Seizure Migraine headache Hypertensive crisis Epidural / Subdural Meningitis / Encephalitis / Brain abscess Tumor

What are the Options?

No thrombolytics Nothing Aspirin Heparin Intravenous rt-PA Other Intra-arterial thrombolytics Low dose IV rt-PA followed by IA rt-PA Investigation procedure

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Treatment Based on CT Findings

CT Findings None Subtle < 1/3 MCA Subtle > 1/3 MCA Hypodensity < 1/3 MCA Hypodensity > 1/3 MCA Recommendations Treat Treat Probably treat Probably treat Dont treat

Exclusions to Thrombolytics
Stroke or head trauma in 3 mos Major surgery within 14 days Any history of intracranial hemorrhage SBP > 185 mm Hg DBP > 110 mm Hg Rapidly improving or minor symptoms Symptoms suggestive of subarachnoid hemorrhage Glucose < 50 or > 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 >15 / INR >1.4

Platelet count <100 X 10/L Patients were also excluded if aggressive measures were required to lower the blood pressure to within speci ed limits

Pretreatment BP Treatment
Gentle management if thrombolytic candidate: SBP > 180 mm Hg DBP > 110 mm Hg Choices: Labetalol 10 - 20 mg IV Enalapril 1.25 mg IV Nitropaste 1 to chest wall No nipride or nitroglycerin gtts

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Treatment Considerations: Who Will Bene t from rt-PA?

Patient age and past medical history (diabetes) Time from onset Blood pressure Stroke severity Stroke subtype CT ndings

Factors Associated with Increased Risk of ICH

Treatment initiated > 3 hours Increased thrombolytic dose Elevated blood pressure NIHSS > 20 * Acute hypodensity or mass eect * * Even though increased r/o ICH, still with bene t vs. placebo

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Treatment Guidelines & Recommendations - Part III

Symptomatic Hemorrhages by NIH Stroke Scale in NINDS Trial
Percentage of Patients that Developed Symptomatic Hemorrhages

Edema or Mass Eect Seen on Initial CT

Source: Broderick, Stroke 1997

Percentage of rt-PA Patients with Symptomatic ICH

Baseline NIH Stroke Scale Score

Source: Broderick, Stroke 1997

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rt-PA Dosing
0.9 mg/kg (max = 90 mg) 10% bolus (over 1 minute) Remainder as a 1 hour infusion Have rt-PA in the Emergency Department

Intra-arterial Thrombolytic Ecacy vs. Time of Delivery

Time from onset (hours)

Source: Ernst, Stroke, 2000

Stroke Treatment - Aspirin

Two important trials: International Stroke Trial (IST) Chinese Acute Stroke Trial (CAST) Combined analysis (n=40,090) Death / nonfatal strokes reduced 11% Dont forget to check swallowing

Stroke Treatment - Heparinoids

Two important trials: International Stroke Trial (IST) TOAST (Trial of ORG 10172) Decreased recurrent ischemic strokes Increased hemorrhagic events No net stroke bene t
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Post-Treatment Guidelines & Recommendations

Post Treatment Care - Antihypertensive Therapy
SBP 180 - 230 or DBP 105-120 mm Hg SBP > 230 or DBP 121 - 140 mm Hg DBP > 140 mm Hg Labetalol 10 mg IV, may repeat / double to 150 mg max Labetalol drip 2-8 mg / min Above Sodium nitroprusside Sodium nitroprusside (0.5 ug/kg per minute)

May consider enalapril in patients with CHF, asthma, abnormal cardiac conduction Check with current guidelines

ICH Contingency Plan

Stat CT STAT labs > ( brinogen, CBC, PT/PTT) Type and screen Fresh frozen plasma Neurosurgical consult

Management of Seizures
Prophylactic anticonvulsant medication not recommended Recurrent seizures require treatment Diazepam 5 mg over 2 minutes Lorazepam 1-4 mg over 210 minutes Follow benzodiazepines with longer acting anticonvulsant (phenytoin, phenobarbital, etc.)

Pneumonia After Stroke

One third of stroke patients develop a pneumonia within 1 month 3rd leading cause of death in the rst month Estimated cost per event $10,000 and a 7 day length of stay Laryngeal cough re ex cough tests can identify patients at risk.

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Source: Addington, Stroke 1999

Rehabilitation
Early rehabilitation is key for recovery Early mobilization also prevents: Deep venous thromboses and pulmonary emboli Decubitus ulcers Contractures Malnutrition Pneumonias UTI

What do you need to treat?

Preplanning and preparation Multidisciplinary approach Know the mechanics Know the risks Coordinated post-treatment care

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Case Study
History, Timeline, and Initial CT Findings
A 61 year old male, with acute aphasia, right facial droop, and right sided weakness. 12:30 12:45 13:05 13:15 13:30 13:45 14:00 14:15 14:20 14:20 Sudden onset while working in yard. Family calls 911. Advanced squad evaluates neurologic de cits and glucose. Squad noti es receiving hospital of possible stroke patient. ED arrival. Initial evaluation by E.D. physician. Stroke Team arrives. NIHSS 18. CT scan performed. Discuss with family and PMD. Labs back: gluc 97. BP remains 150/70s. CT reading back. (See below.) No hemorrhage or early signs of ischemia.

14:25 14:30 14:35

Checklist done. No exclusion criteria met. Decision time. IV rt-PA given. 0.9 mg/kg total 10% bolus - 9 mg

15:45 15:50

90% over 1 hr - 81 mg Patient goes to ICU. Report personally given to ICU sta. Pathway actions begin (HOB, BP parameters, aspiration precautions).

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24 Hour Follow-up
A 61 year old male, with acute stroke, treated with rt-PA. Repeat NIHSS = 3: VF intact No gaze palsy Mild facial palsy Mild right arm drift Mild dysarthria Repeat CT shows areas of infarct:

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Carotid U/S shows 60-80% stenosis left ICA

Speech recommends swallowing II diet and daily checks Physical therapy pending CEA performed day 3 Patient discharged to home on day 7 near pre-stroke baseline.

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References
Jorgensen HS, Nakayama H, Raaschou HO, Gam J, Olsen TS. "Silent infarction in acute stroke patients. Prevalence, localization, risk factors, and clinical signi cance: the Copenhagen Stroke Study." Stroke 1994 Jan;25(1):97-104 Fagan SC, Morgenstern LB, Petitta A, Ward RE, Tilley BC, Marler JR, Levine SR, Broderick JP, Kwiatkowski TG, Frankel M, Brott TG, Walker MD. "Cost-eectiveness of tissue plasminogen activator for acute ischemic stroke." NINDS rt-PA Stroke Study Group. Neurology 1998 Apr;50(4):883-90 Ronning OM, Guldvog B "Should stroke victims routinely receive supplemental oxygen? A quasirandomized controlled trial." Stroke 1999 Oct;30(10):2033-7 Brott T, Broderick J, Kothari R, Barsan W, Tomsick T, Sauerbeck L, Spilker J, Duldner J, Khoury J "Early hemorrhage growth in patients with intracerebral hemorrhage." Stroke 1997 Jan;28(1):1-5 Ernst R, Pancioli A, Tomsick T, Kissela B, Woo D, Kanter D, Jauch E, Carrozzella J, Spilker J, Broderick J "Combined intravenous and intra-arterial recombinant tissue plasminogen activator in acute ischemic stroke." Stroke 2000 Nov;31(11):2552-7 Addington WR, Stephens RE, Gilliland KA "Assessing the laryngeal cough re ex and the risk of developing pneumonia after stroke: an interhospital comparison." Stroke 1999 Jun;30(6):1203-7 Abstracts from all of Dr. Jauch's publications are available at PubMed.

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