ACUTE STROKE IDENTIFICATION AND TREATMENT (“TIME IS BRAIN”) Andy Jagoda, MD, FACEP Department of Emergency Medicine Mount Sinai School of Medicine New.

ACUTE ACUTE STROKESTROKE IDENTIFICATION AND TREATMENT IDENTIFICATION AND TREATMENT

(“TIME IS BRAIN”)(“TIME IS BRAIN”)

Andy Jagoda, MD, FACEPAndy Jagoda, MD, FACEPDepartment of Emergency MedicineDepartment of Emergency Medicine

Mount Sinai School of MedicineMount Sinai School of MedicineNew York, New YorkNew York, New York

Andy Jagoda, MD

A 58 yo man experiences one half hour of A 58 yo man experiences one half hour of numbness and weakness in his left arm. When numbness and weakness in his left arm. When he arrives in the ED his symptoms have he arrives in the ED his symptoms have resolved. PMH: positive for CAD. Meds: resolved. PMH: positive for CAD. Meds: Enalapril. PE: no focal deficits. ECG: NSR.Enalapril. PE: no focal deficits. ECG: NSR.Should this patient be admitted to the hospital?Should this patient be admitted to the hospital?

a. yesa. yes

b. nob. no

Andy Jagoda, MD

The patient is discharged for an outpatient The patient is discharged for an outpatient workup. Three weeks later he develops left face workup. Three weeks later he develops left face and arm weakness. EMS is called. Which of the and arm weakness. EMS is called. Which of the following is the best choice?following is the best choice?

a. He should be taken to the closest hospitala. He should be taken to the closest hospital

b. He should be taken to the closest hospital b. He should be taken to the closest hospital with a designated stroke teamwith a designated stroke team

Andy Jagoda, MD

The patient arrives in the ED, one hour after The patient arrives in the ED, one hour after onset of symptoms, with no improvement. Blood onset of symptoms, with no improvement. Blood pressure since EMS arrived has remained pressure since EMS arrived has remained 170/100. Which of the following is the best blood 170/100. Which of the following is the best blood pressure management?pressure management?

a. sl nitroglycerina. sl nitroglycerin

b. po clonidine b. po clonidine

c. iv labetololc. iv labetolol

d. no treatmentd. no treatment

Andy Jagoda, MD

A CT is obtained within 90 minutes of symptom A CT is obtained within 90 minutes of symptom onset: It is read by a neuroradiologist and shows onset: It is read by a neuroradiologist and shows no signs of edema, infarct, or hemorrhage. no signs of edema, infarct, or hemorrhage. Which of the following would you recommend?Which of the following would you recommend?

a. t-PAa. t-PA

b. aspirinb. aspirin

c. heparinc. heparin

d. a plus b or cd. a plus b or c

e. supportive caree. supportive care

Andy Jagoda, MD

INTRODUCTIONINTRODUCTION

• Stroke is the 3ird most common cause of deathStroke is the 3ird most common cause of death– Second most common cause for patient to be in a Second most common cause for patient to be in a

nursing homenursing home

• 500,000 - 700,000 strokes / year500,000 - 700,000 strokes / year– 80 - 90% Ischemic80 - 90% Ischemic

– 10 - 20% Hemorrhagic or SAH10 - 20% Hemorrhagic or SAH

– 30% Mortality within 3months30% Mortality within 3months

• Leading cause of disabilityLeading cause of disability– 3 million with stroke related disability3 million with stroke related disability

• Estimated $ 40 billion annual heath care cost Estimated $ 40 billion annual heath care cost **

* TAYLOR ET AL. STROKE 1996;27:1459* TAYLOR ET AL. STROKE 1996;27:1459

Andy Jagoda, MD

The FactsThe Facts

• TIAsTIAs– 20% of stroke patients have a preceding TIA20% of stroke patients have a preceding TIA– 75% resolve in <15 minutes; 97% <3 hours75% resolve in <15 minutes; 97% <3 hours

• StrokeStroke– 5.4% recurrent symptomatic stroke within 1 year5.4% recurrent symptomatic stroke within 1 year– 28% mortality within 1 year (40-60% related to stroke)28% mortality within 1 year (40-60% related to stroke)

• Acute strokeAcute stroke– ICH within 36 hours: 1% symptomatic, 4% asymptomaticICH within 36 hours: 1% symptomatic, 4% asymptomatic– 25% have little or no disability at 3 months25% have little or no disability at 3 months– 25% have mild to moderate disability at 3 months25% have mild to moderate disability at 3 months– 30% have severe disability30% have severe disability– 20% dead at 3 months 20% dead at 3 months

Andy Jagoda, MD

Transient Ischemic AttackTransient Ischemic Attack

• Cerebrovascular event with deficit <24 hoursCerebrovascular event with deficit <24 hours• Symptoms in a vascular territorySymptoms in a vascular territory• Risk of stroke:Risk of stroke:

– 25% by 5 years25% by 5 years– 15% by 1 year 15% by 1 year – 10% at 3 months10% at 3 months– 5% at 48 hours5% at 48 hours

• Anticoagulation indicated in atrial fibrillation, patent Anticoagulation indicated in atrial fibrillation, patent foramen ovale, carotid / vertebral artery stenosisforamen ovale, carotid / vertebral artery stenosis

• Endarterectomy reduces risk by 10% at 2 yearsEndarterectomy reduces risk by 10% at 2 years

Andy Jagoda, MD

Transient Ischemic AttackTransient Ischemic Attack

• Benefits of hospitalizationBenefits of hospitalization– Facilitates diagnostic evaluationFacilitates diagnostic evaluation– Allows observation and rapid management for strokeAllows observation and rapid management for stroke

• Hospitalization indicated for:Hospitalization indicated for:– Suspected cardio-embolismSuspected cardio-embolism– Patients > 60Patients > 60– DiabetesDiabetes– Symptom duration > 10 minutesSymptom duration > 10 minutes– WeaknessWeakness– Speech impairmentSpeech impairment

• Initiate anti-platelet therapy (aspirin, clopidigrel)Initiate anti-platelet therapy (aspirin, clopidigrel)

Andy Jagoda, MD

SUBTYPES OF STROKESUBTYPES OF STROKE

• HEMORRHAGICHEMORRHAGIC– INTRACEREBRAL HEMORRHAGEINTRACEREBRAL HEMORRHAGE

– SUBARACHNOID HEMORRHAGESUBARACHNOID HEMORRHAGE

• ISCHEMIC LARGE ARTERY ATHEROSCLEROSIS ISCHEMIC LARGE ARTERY ATHEROSCLEROSIS WITH THROMBOEMBOLISMWITH THROMBOEMBOLISM

– SMALL VESSEL DISEASESMALL VESSEL DISEASE

– CARDIOEMBOLISMCARDIOEMBOLISM

– NONARTHEROSCLEROTIC VASCULOPATHIESNONARTHEROSCLEROTIC VASCULOPATHIES

– HYPERCOAGULABLE STATESHYPERCOAGULABLE STATES

Andy Jagoda, MD

GOALS IN STROKE MANAGEMENTGOALS IN STROKE MANAGEMENT

• DEFINE ETIOLOGYDEFINE ETIOLOGY– CONSIDER CONDITIONS THAT MASQUERADE AS STROKE: CONSIDER CONDITIONS THAT MASQUERADE AS STROKE:

COMPLICATED MIGRAINE, TODD’S PARALYSIS, COMPLICATED MIGRAINE, TODD’S PARALYSIS, HYPOGLYCEMIA, FUNCTIONALHYPOGLYCEMIA, FUNCTIONAL

• DO NO HARMDO NO HARM– DO NOT OVERTREAT BLOOD PRESSUREDO NOT OVERTREAT BLOOD PRESSURE

– MANAGE BLOOD SUGARMANAGE BLOOD SUGAR

• LIMIT INFARCT SIZELIMIT INFARCT SIZE– ROLE OF THROMBOLYTICSROLE OF THROMBOLYTICS

– NEUROPROTECTIVE AGENTSNEUROPROTECTIVE AGENTS

• PREVENT COMPLICATIONSPREVENT COMPLICATIONS

• INITIATE EARLY REHABILITATIONINITIATE EARLY REHABILITATION

Andy Jagoda, MD

NINDS PROCEEDINGS: 1997NINDS PROCEEDINGS: 1997

• PUBLIC EDUCATIONPUBLIC EDUCATION

• PREHOSPITAL EMERGENCY RESPONSEPREHOSPITAL EMERGENCY RESPONSE

• DESIGNATED STROKE CENTERSDESIGNATED STROKE CENTERS

• EMERGENCY DEPARTMENTSEMERGENCY DEPARTMENTS

• HOSPITAL STROKE UNITSHOSPITAL STROKE UNITS

• REHABILITATIONREHABILITATION

Andy Jagoda, MD

PUBLIC EDUCATIONPUBLIC EDUCATION

• NINDS STROKE TRIAL, 17,000 PATIENTS, ONLY 3.6% WERE NINDS STROKE TRIAL, 17,000 PATIENTS, ONLY 3.6% WERE ELIGIBLE FOR TREATMENTELIGIBLE FOR TREATMENT

• AGGRESSIVE PUBLIC CAMPAIGNS HAVE DECREASED TIME AGGRESSIVE PUBLIC CAMPAIGNS HAVE DECREASED TIME OF ONSET TO TIME OF ED ARRIVAL TO < 3 HOURS IN 50% OF OF ONSET TO TIME OF ED ARRIVAL TO < 3 HOURS IN 50% OF PATIENTS PATIENTS **

• FACTORS ASSOCIATED WITH DELAYFACTORS ASSOCIATED WITH DELAY– NO SYMPTOM RECOGNITIONNO SYMPTOM RECOGNITION

– LIVING ALONELIVING ALONE

– NIGHTTIME ONSETNIGHTTIME ONSET

– CALL TO MDCALL TO MD

MORRIS ET AL. ACAD EMERG MED 1996;3:539MORRIS ET AL. ACAD EMERG MED 1996;3:539

BARSAN ET AL. ARCH INT MED 1993;153:2558BARSAN ET AL. ARCH INT MED 1993;153:2558

Andy Jagoda, MD

CHAIN OF RECOVERYCHAIN OF RECOVERY

• MI: TRAUMA: STROKEMI: TRAUMA: STROKE

• RAPID ON-SCENE IDENTIFICATION OF LIFE-RAPID ON-SCENE IDENTIFICATION OF LIFE-THREATENING PROBLEMSTHREATENING PROBLEMS

• RAPID EVACUATION TO APPROPRIATE FACILITY WITH RAPID EVACUATION TO APPROPRIATE FACILITY WITH PRENOTIFICATIONPRENOTIFICATION

• RAPID DIAGNOSISRAPID DIAGNOSIS

• RAPID DEFINITIVE INTERVENTIONSRAPID DEFINITIVE INTERVENTIONS

• SPECIALIZED IN-PATIENT MANAGEMENTSPECIALIZED IN-PATIENT MANAGEMENT

• REHABILITATIONREHABILITATION

Andy Jagoda, MD

THE PUBLIC MESSAGETHE PUBLIC MESSAGE

• WEAKNESS OR NUMBNESS ON ONE SIDE OF THE WEAKNESS OR NUMBNESS ON ONE SIDE OF THE

BODYBODY

• DIFFICULTY WITH VISION DIFFICULTY WITH VISION

• DIFFICULTY WITH SPEECH OR UNDERSTANDINGDIFFICULTY WITH SPEECH OR UNDERSTANDING

• UNUSUALLY SEVERE HEADACHEUNUSUALLY SEVERE HEADACHE

• DIZZINESS OR UNSTEADINESSDIZZINESS OR UNSTEADINESS

Andy Jagoda, MD

STROKE IS A BRAIN ATTACK.STROKE IS A BRAIN ATTACK.

CALL 911CALL 911**PUBLIC SERVICE ANNOUNCEMENT. JANUARY 1998PUBLIC SERVICE ANNOUNCEMENT. JANUARY 1998

Andy Jagoda, MD

EMS DISPATCH IN ACUTE STROKEEMS DISPATCH IN ACUTE STROKE

• PRIORITY DISPATCH SYSTEMSPRIORITY DISPATCH SYSTEMS– GOAL: TO SEND THE RIGHT THINGS TO THE RIGHT PEOPLE GOAL: TO SEND THE RIGHT THINGS TO THE RIGHT PEOPLE

AT THE RIGHT TIME IN THE RIGHT WAY “ (NHAAP, NIH, 1994)AT THE RIGHT TIME IN THE RIGHT WAY “ (NHAAP, NIH, 1994)

• 911911– STILL NOT AVAILABLE TO 15% OF POPULATIONSTILL NOT AVAILABLE TO 15% OF POPULATION

– BASIC 911 REQUIRES PATIENT PARTICIPATIONBASIC 911 REQUIRES PATIENT PARTICIPATION

– ADVANCED 911, CALLER IDADVANCED 911, CALLER ID

• EMS DISPATCHERS IDENTIFY ONLY 51% OF STROKES EMS DISPATCHERS IDENTIFY ONLY 51% OF STROKES (KOTHARI. STROKE 1996;27:171)(KOTHARI. STROKE 1996;27:171)

• ARRIVAL TO ED FROM SYMPTOM ONSETARRIVAL TO ED FROM SYMPTOM ONSET– 7% WITHIN 1 HR 7% WITHIN 1 HR (JORGESEN. NEUROLOGY 1996;47:383)(JORGESEN. NEUROLOGY 1996;47:383)

– 2.6 HOURS 2.6 HOURS (BARSAN. ARCH INT MED 1993;153:2558)(BARSAN. ARCH INT MED 1993;153:2558)

Andy Jagoda, MD

PREHOSPITAL CARE IN STROKEPREHOSPITAL CARE IN STROKE

• UP TO 25% OF PATIENTS WITH ACUTE STROKE UP TO 25% OF PATIENTS WITH ACUTE STROKE

REQUIRE ADVANCED CARE DURING TRANSPORT:REQUIRE ADVANCED CARE DURING TRANSPORT:

– AIRWAY MANAGEMENTAIRWAY MANAGEMENT

– SEIZURE CONTROLSEIZURE CONTROL

– RECOGNITION OF MI AND DYSRHYTHMIASRECOGNITION OF MI AND DYSRHYTHMIAS

KOTARI ET AL. STROKE 1995;26:937KOTARI ET AL. STROKE 1995;26:937

Andy Jagoda, MD

PREHOSPITAL STROKE SCALEPREHOSPITAL STROKE SCALE

FOCUSED EXAM TO MINIMIZE FIELD TIME AND TO ACTIVATE FOCUSED EXAM TO MINIMIZE FIELD TIME AND TO ACTIVATE STROKE TEAMSTROKE TEAM

• FACIAL DROOPFACIAL DROOP– SYMMETRICAL MOVEMENTSYMMETRICAL MOVEMENT

– ASYMMETRIC MOVEMENTASYMMETRIC MOVEMENT

• MOTOR WEAKNESSMOTOR WEAKNESS– NO MOVEMENT OR PRONATOR DRIFTNO MOVEMENT OR PRONATOR DRIFT

• SPEECH: REPEAT A PHRASESPEECH: REPEAT A PHRASE– SLURS WORDS, USES INAPPROPRIATE WORDS, OR IS UNABLE SLURS WORDS, USES INAPPROPRIATE WORDS, OR IS UNABLE

TO SPEAKTO SPEAK

KOTARI ET AL. ACAD EMERG MED 1997;4:986KOTARI ET AL. ACAD EMERG MED 1997;4:986

Andy Jagoda, MD

THE STROKE TEAM / STROKE CENTERSTHE STROKE TEAM / STROKE CENTERS

• GOAL:GOAL:– To provide comprehensive, coordinated careTo provide comprehensive, coordinated care

– To identify candidates for thrombolytics within 3 hours To identify candidates for thrombolytics within 3 hours

• TEAM:TEAM:– Physicians with expertise in strokePhysicians with expertise in stroke

– NurseNurse

– CT personnelCT personnel

• AVAILABILITY:AVAILABILITY:– 24 hours / day / 7 days a week24 hours / day / 7 days a week

Alberts et al. Recommendations for the establishment of primary stroke Alberts et al. Recommendations for the establishment of primary stroke centers. JAMA 2000; 283:31-2-3109centers. JAMA 2000; 283:31-2-3109

Andy Jagoda, MD

IDEAL RESPONSE TIMESIDEAL RESPONSE TIMES

• ED arrival within one hour of symptomsED arrival within one hour of symptoms

• Evaluation within 10 minutes of arrivalEvaluation within 10 minutes of arrival

• Stroke team notification within 15 minStroke team notification within 15 min

• CT within 25 minutesCT within 25 minutes

• CT interpretation within 45 minutesCT interpretation within 45 minutes

• Thrombolytics for eligible patients within 60 Thrombolytics for eligible patients within 60 minutes minutes

• Transfer to a stroke unit within 3 hours or arrivalTransfer to a stroke unit within 3 hours or arrival

Andy Jagoda, MD

THE STROKE TEAMTHE STROKE TEAM

• EMS NOTIFICATIONEMS NOTIFICATION

• TEAM ACTIVATIONTEAM ACTIVATION

• STANDING ORDERS:STANDING ORDERS:– VITAL SIGN MONITORINGVITAL SIGN MONITORING

– RAPID GLUCOSE DETERMINATIONRAPID GLUCOSE DETERMINATION

– NEUROLOGICAL MONITORINGNEUROLOGICAL MONITORING

– ECG / CARDIAC MONITORINGECG / CARDIAC MONITORING

– IV ACCESSIV ACCESS

– LABORATORY STUDIES: CBC, LYTES, PT/PTT, TYPE AND LABORATORY STUDIES: CBC, LYTES, PT/PTT, TYPE AND SCREENSCREEN

– PORTABLE CXRPORTABLE CXR

– HEAD CTHEAD CT

Andy Jagoda, MD

EMERGENCY DEPARTMENT APPROACH EMERGENCY DEPARTMENT APPROACH TO STROKE: HISTORYTO STROKE: HISTORY

• TIME OF ONSETTIME OF ONSET

• HEAD TRAUMAHEAD TRAUMA

• SEIZURESEIZURE

• MEDICATIONS: USE OF ANTICOAGULANTSMEDICATIONS: USE OF ANTICOAGULANTS

• SYMPTOMS SUGGESTIVE OF MISYMPTOMS SUGGESTIVE OF MI– CHEST PAIN, PALPITATIONS, SOBCHEST PAIN, PALPITATIONS, SOB

• SYMPTOMS SUGGESTIVE OF HEMORRHAGESYMPTOMS SUGGESTIVE OF HEMORRHAGE– SEVERE HEADACHESEVERE HEADACHE

– NECK STIFFNESS / PAINNECK STIFFNESS / PAIN

– NAUSEA / VOMITINGNAUSEA / VOMITING

Andy Jagoda, MD

ED APPROACH TO STROKE: PHYSICALED APPROACH TO STROKE: PHYSICAL

• ABC’SABC’S

• Vital signs (BP both arms; presence of fever)Vital signs (BP both arms; presence of fever)

• LOC (when depressed, consider other diagnoses)LOC (when depressed, consider other diagnoses)

• Trauma examTrauma exam

• Neck examNeck exam

• Cardiopulmonary examCardiopulmonary exam

• Neurologic examNeurologic exam– Glasgow coma scaleGlasgow coma scale

– NIHSS: 15 Item measure: 42 Points NIHSS: 15 Item measure: 42 Points » < 4 Not a candidate for thrombolytics

» > 22 Increased risk for hemorrhage

Andy Jagoda, MD

NIH Stroke ScaleNIH Stroke Scale

• Level of Level of consciousnessconsciousness

• Orientation (month Orientation (month and age)and age)

• Follow commandsFollow commands• Best gazeBest gaze• Visual fieldsVisual fields• Facial palsyFacial palsy

• Motor armMotor arm• Motor legMotor leg• Limb ataxia SensoryLimb ataxia Sensory• Best languageBest language• DysarthriaDysarthria• Extinction and Extinction and

inattention (neglect)inattention (neglect)

Andy Jagoda, MD

Stroke MimicsStroke Mimics

• Todd’s paralysisTodd’s paralysis• Complicated migraineComplicated migraine• Nonconvulsive status Nonconvulsive status

epilepticusepilepticus• NeuropathyNeuropathy• HypoglycemiaHypoglycemia• HyperglycemiaHyperglycemia

Andy Jagoda, MD

Stroke Localization PearlsStroke Localization Pearls

• Aphasia usually corresponds to left hemispheric Aphasia usually corresponds to left hemispheric stroke (right sided weakness)stroke (right sided weakness)

• Neglect (hemi-attention) usually indicates right Neglect (hemi-attention) usually indicates right hemispheric strokehemispheric stroke

• Patients usually look towards the lesionPatients usually look towards the lesion• Crossed signs indicated brainstem involvementCrossed signs indicated brainstem involvement• Vertigo of central origin almost always is Vertigo of central origin almost always is

associated with other cranial nerve deficitsassociated with other cranial nerve deficits• Vertical nystagmus is posterior circulation Vertical nystagmus is posterior circulation

ischemia until proven otherwise ischemia until proven otherwise

Andy Jagoda, MD

CONTROVERSIES IN STROKE CONTROVERSIES IN STROKE MANAGEMENTMANAGEMENT

• USE OF DEXTROSEUSE OF DEXTROSE

• MANAGEMENT OF BLOOD PRESSUREMANAGEMENT OF BLOOD PRESSURE

• USE OF THROMBOLYTICSUSE OF THROMBOLYTICS

• USE OF HEPARINUSE OF HEPARIN

Andy Jagoda, MD

BLOOD PRESSURE MANAGEMENT IN BLOOD PRESSURE MANAGEMENT IN ISCHEMIC STROKEISCHEMIC STROKE

• Loss of autoregulation in ischemic brain: CBF depends on Loss of autoregulation in ischemic brain: CBF depends on arterial BP to maintain cerebral perfusionarterial BP to maintain cerebral perfusion

• Most ischemic stroke patients have a history of Most ischemic stroke patients have a history of hypertension and need higher CPPhypertension and need higher CPP

• In general, there is a spontaneous decline in BP over timeIn general, there is a spontaneous decline in BP over time

• Lowering BP may exacerbate brain ischemiaLowering BP may exacerbate brain ischemia

ADAMS ET AL. STROKE 1994;25:1901ADAMS ET AL. STROKE 1994;25:1901

STRANDGAARD. CIRCULATION 1976;53:720STRANDGAARD. CIRCULATION 1976;53:720

Andy Jagoda, MD

BLOOD PRESSURE MANAGEMENT IN BLOOD PRESSURE MANAGEMENT IN ISCHEMIC STROKEISCHEMIC STROKE

• Systolic 185 - 220, Diastolic 105 - 120; Do not Systolic 185 - 220, Diastolic 105 - 120; Do not treat for the first hour (consider benzodiazepines); treat for the first hour (consider benzodiazepines); if persists, IV Labetolol, 10 mg.if persists, IV Labetolol, 10 mg.

• Systolic > 220 mm Hg or diastolic 121 - 140; 2 Systolic > 220 mm Hg or diastolic 121 - 140; 2 readings 20 min apart: Start readings 20 min apart: Start LabetololLabetolol 10 MG IV. 10 MG IV. Patients requiring more than 2 doses are not Patients requiring more than 2 doses are not candidates for t-PA candidates for t-PA

• Diastolic > 140 mm Hg; 2 readings 5 minutes Diastolic > 140 mm Hg; 2 readings 5 minutes apart: Start apart: Start NitroprussideNitroprusside. Patient is not a . Patient is not a candidate for t-PAcandidate for t-PA

Andy Jagoda, MD

BLOOD PRESSURE MANAGEMENT IN BLOOD PRESSURE MANAGEMENT IN ISCHEMIC STROKEISCHEMIC STROKE

• HYPOTENSION IN ACUTE STROKEHYPOTENSION IN ACUTE STROKE

– DEHYDRATIONDEHYDRATION

– ARRHYTHMIAARRHYTHMIA

– DIMINISHED CARDIAC OUTPUTDIMINISHED CARDIAC OUTPUT

• TREAT UNDERLYING CAUSETREAT UNDERLYING CAUSE

– FLUIDSFLUIDS

– RHYTHM CONTROLRHYTHM CONTROL

– PRESSORSPRESSORS

Andy Jagoda, MD

BLOOD PRESSURE MANAGEMENT IN BLOOD PRESSURE MANAGEMENT IN HEMORRHAGIC STROKEHEMORRHAGIC STROKE

• NO STUDIES TO SHOW LOWERING BP DECREASES NO STUDIES TO SHOW LOWERING BP DECREASES

RISK OF REBLEEDING OR IMPROVES OUTCOMERISK OF REBLEEDING OR IMPROVES OUTCOME

• NINDS RECOMMENDS INTERVENTION WHEN THE NINDS RECOMMENDS INTERVENTION WHEN THE

SYSTOLIC > 180, DIASTOLIC > 130SYSTOLIC > 180, DIASTOLIC > 130

• GOAL IS TO LOWER THE BP TO A MAP OF 130 mm Hg GOAL IS TO LOWER THE BP TO A MAP OF 130 mm Hg

(10 - 20%)(10 - 20%)

• NITROPRUSSIDE OR LABETOLOLNITROPRUSSIDE OR LABETOLOL

Andy Jagoda, MD

Use of Thrombolytics: Review of the literatureUse of Thrombolytics: Review of the literature

Andy Jagoda, MD

NINDSNINDS

• Randomized, double blind study; 624 patientsRandomized, double blind study; 624 patients• t-PA .9 mg/kg (max 90 mg) within 3 hours onsett-PA .9 mg/kg (max 90 mg) within 3 hours onset• Statistically significant benefit in outcome at 3 and Statistically significant benefit in outcome at 3 and

12 months12 months• No change in mortality and a decrease in LOSNo change in mortality and a decrease in LOS

Andy Jagoda, MD

Alpers et al. The standard treatment with Alteplase to Alpers et al. The standard treatment with Alteplase to reverse stroke study (STARS). JAMA 2000; 283:1145-1150reverse stroke study (STARS). JAMA 2000; 283:1145-1150

• Prospective, multi-center phase IV study: 2/97 - 12/98Prospective, multi-center phase IV study: 2/97 - 12/98– Designed to assess safety profile and outcome findings. Designed to assess safety profile and outcome findings. – 57 or 83 centers in ATLANTIS participated57 or 83 centers in ATLANTIS participated

• 389 patients389 patients– median time of tx 2 hours and 44 minutesmedian time of tx 2 hours and 44 minutes– median NIHSS score 13 (vs 14 in NINDS)median NIHSS score 13 (vs 14 in NINDS)– 19% NIHSS score >20 (vs 20% in NINDS)19% NIHSS score >20 (vs 20% in NINDS)– 6% with cerebral edema on initial CT (vs 4% NINDS)6% with cerebral edema on initial CT (vs 4% NINDS)

• 3 day rate ICH: 3 day rate ICH: – 3.3% symptomatic (vs 6.4% NINDS) 3.3% symptomatic (vs 6.4% NINDS) – 7% asymptomatic7% asymptomatic– 1.5% major systemic bleeding1.5% major systemic bleeding

Andy Jagoda, MD

Alpers et al. The standard treatment with Alteplase to reverse Alpers et al. The standard treatment with Alteplase to reverse stroke study (STARS). JAMA 2000; 283:1145-1150stroke study (STARS). JAMA 2000; 283:1145-1150

• 35% violations of the NINDS protocol35% violations of the NINDS protocol– 13% treated beyond the 3 hour window13% treated beyond the 3 hour window– 9% received anticoagulants within 24 hours9% received anticoagulants within 24 hours– 7% treated with BPs > 185 mm Hg7% treated with BPs > 185 mm Hg– Symptomatic ICH occurred in 3.9% (vs 3.1%; trend Symptomatic ICH occurred in 3.9% (vs 3.1%; trend

towards significance)towards significance)

• 30 day outcome (NINDS measured at 90 days)30 day outcome (NINDS measured at 90 days)– 13% mortality13% mortality– 35 % very favorable outcome; Rankin <135 % very favorable outcome; Rankin <1– 8% functionally independent: Rankin 1-28% functionally independent: Rankin 1-2– 12% moderate disability: Rankin 312% moderate disability: Rankin 3– 31% moderate to severe disability: Rankin 431% moderate to severe disability: Rankin 4

Andy Jagoda, MD

Alpers et al. The standard treatment with Alteplase to Alpers et al. The standard treatment with Alteplase to reverse stroke study (STARS). JAMA 2000; 283:1145-1150reverse stroke study (STARS). JAMA 2000; 283:1145-1150

• Predictors of favorable outcome:Predictors of favorable outcome:– NIHSS score of 10 or lessNIHSS score of 10 or less– Absence of specific abnormalities on the baseline CT Absence of specific abnormalities on the baseline CT

(hypodensity > 1/3 MCA associated with ICH)(hypodensity > 1/3 MCA associated with ICH)– Age < 86Age < 86

• Odds of recovery (OCD)Odds of recovery (OCD)– For every 5 point increase in baseline NIHSS score, patients For every 5 point increase in baseline NIHSS score, patients

had a 22% decrease in the OCDhad a 22% decrease in the OCD– NIHSS scores greater than 10 had a 75% decrease in the OCDNIHSS scores greater than 10 had a 75% decrease in the OCD– Every 10 point increase in baseline mean BP decreased the Every 10 point increase in baseline mean BP decreased the

OCD by 19%OCD by 19%

• Results replicated the NINDS studyResults replicated the NINDS study

Andy Jagoda, MD

Katzan et al. Use of t-PA: The Cleveland Katzan et al. Use of t-PA: The Cleveland experience. JAMA 2000; 283:1151-1158experience. JAMA 2000; 283:1151-1158

• Retrospective review of Cleveland experience Retrospective review of Cleveland experience using data from stroke registry from 29 using data from stroke registry from 29 hospitals,over a one year period, 1997-1998hospitals,over a one year period, 1997-1998

• Stroke patients identified using ICD-9 codesStroke patients identified using ICD-9 codes• 4345 ischemic strokes4345 ischemic strokes• 17% admitted within 3 hours17% admitted within 3 hours• 70 patients received t-PA: 1.8% of all stroke 70 patients received t-PA: 1.8% of all stroke

patients, 10.4% of eligible patientspatients, 10.4% of eligible patients– 16 of 29 hospitals used t-PA16 of 29 hospitals used t-PA

• 669 matched patients who did not receive t-PA669 matched patients who did not receive t-PA

Andy Jagoda, MD

Katzan et al. Use of t-PA: The Cleveland Katzan et al. Use of t-PA: The Cleveland experience. JAMA 2000; 283:1151-1158experience. JAMA 2000; 283:1151-1158

• In-hospital mortality: 16% t-PA vs 7.1% no t-PA In-hospital mortality: 16% t-PA vs 7.1% no t-PA – 5% mortality in the general stroke population5% mortality in the general stroke population

• ICH rate 22%; 15.7% symptomaticICH rate 22%; 15.7% symptomatic– 50% of deaths were in the symptomatic ICH group50% of deaths were in the symptomatic ICH group

• Patients treated with t-PA were discharged home Patients treated with t-PA were discharged home significantly less often than those not treatedsignificantly less often than those not treated

Andy Jagoda, MD

Katzan et al. Use of t-PA: The Cleveland Katzan et al. Use of t-PA: The Cleveland experience. JAMA 2000; 283:1151-1158experience. JAMA 2000; 283:1151-1158

• 50% violation of treatment guidelines 50% violation of treatment guidelines – 37% treated with antithrombotics37% treated with antithrombotics– 13% treated outside of 3 hours13% treated outside of 3 hours– 7% SBP > 185 or DBP >1107% SBP > 185 or DBP >110

• NIHSS score not documented in 60%NIHSS score not documented in 60%– median score of 12median score of 12

• Deviation in BP treatment / monitoring 86%Deviation in BP treatment / monitoring 86%

Andy Jagoda, MD

Katzan et al. Use of t-PA: The Cleveland Katzan et al. Use of t-PA: The Cleveland experience. JAMA 2000; 283:1151-1158experience. JAMA 2000; 283:1151-1158

• Limited data on stroke severityLimited data on stroke severity• 50% receiving treatment had deviations from the 50% receiving treatment had deviations from the

NINDS treatment standardsNINDS treatment standards– no significant correlation between deviations and no significant correlation between deviations and

symptomatic ICHsymptomatic ICH

• Neurologic outcomes were not trackedNeurologic outcomes were not tracked

Andy Jagoda, MD

DECIDING TO USE THROMBOLYTICSDECIDING TO USE THROMBOLYTICS

• UP TO 20% OF PATIENTS ARE INCORRECTLY DIAGNOSED AS UP TO 20% OF PATIENTS ARE INCORRECTLY DIAGNOSED AS

HAVING A STROKEHAVING A STROKE

• EXPERTISE IN STROKE MANAGEMENT NEEDEDEXPERTISE IN STROKE MANAGEMENT NEEDED

• EXCLUSION:EXCLUSION:

– CT SIGNS OF HEMORRHAGE OR INFARCTIONCT SIGNS OF HEMORRHAGE OR INFARCTION

– UNDETERMINED TIME OF ONSETUNDETERMINED TIME OF ONSET

– UNCONTROLLED HYPERTENSIONUNCONTROLLED HYPERTENSION

– RAPIDLY RESOLVING NEURO DEFICITSRAPIDLY RESOLVING NEURO DEFICITS

» UNRESOLVING NEURO DEFICIT LASTING > 90 MIN, LESS THAN 3% UNRESOLVING NEURO DEFICIT LASTING > 90 MIN, LESS THAN 3%

ARE TIAsARE TIAs

Andy Jagoda, MD

STROKE UNITSSTROKE UNITS

• IMPROVES OUTCOME IMPROVES OUTCOME **– OPTIMIZES CHANCE OF RECOVERYOPTIMIZES CHANCE OF RECOVERY

– MINIMIZES COMPLICATIONSMINIMIZES COMPLICATIONS

– DECREASE LENGTH OF HOSPITAL STAYDECREASE LENGTH OF HOSPITAL STAY

• PROVIDES ONGOING MONITORINGPROVIDES ONGOING MONITORING– NEUROLOGIC DETERIORATION (4-8% SEIZURE)NEUROLOGIC DETERIORATION (4-8% SEIZURE)

– CARDIAC DYSRHYTHMIAS (CARDIAC ETIOLOGY IN 14% OF POST-CARDIAC DYSRHYTHMIAS (CARDIAC ETIOLOGY IN 14% OF POST-STROKE DEATHS)STROKE DEATHS)

– DECREASES INCIDENCE OF PE, PNEUMONIA (30% OF STROKE DEATHS)DECREASES INCIDENCE OF PE, PNEUMONIA (30% OF STROKE DEATHS)

• FACILITATES DIAGNOSTIC WORK-UPFACILITATES DIAGNOSTIC WORK-UP

• ENSURES EARLY REHABILITATION, PATIENT AND FAMILY ENSURES EARLY REHABILITATION, PATIENT AND FAMILY EDUCATIONEDUCATION

* LANGHORNE ET AL. LANCET 1993;342:395* LANGHORNE ET AL. LANCET 1993;342:395

Andy Jagoda, MD

CONCLUSIONSCONCLUSIONS

• New treatment for stroke makes rapid diagnosis criticalNew treatment for stroke makes rapid diagnosis critical

• Chain of survival begins with public education and rapid Chain of survival begins with public education and rapid access to definitive careaccess to definitive care

• Identification of hospitals prepared to provide Identification of hospitals prepared to provide comprehensive care is fundamental comprehensive care is fundamental

• Stroke teams are critical to ensure efficient stroke Stroke teams are critical to ensure efficient stroke management management

• Continuous quality improvement programs are needed to Continuous quality improvement programs are needed to assess effectiveness and identify needsassess effectiveness and identify needs