PowerPoint Presentation€¦ · • If NIHSS > 6, obtain STAT CT Head Angio to eval for LVO. • If LVO, arrange for immediate mechanical thrombectomy. • rtPA approval window up

3/21/2017

1

Management of

Acute Ischemic

Stroke

Mindy Mason, MSN, RN, ACNP-BC

University of New MexicoAcademic Medical Center

Level I Trauma Center

24 bed Neuroscience ICU

Albuquerque, NM

“The Clock is Ticking”

Objectives:

• Define “Stroke”

• Identify the incidence and prevalence of acute

ischemic stroke

• Brief overview of causes of ischemic stroke

• Describe the most common stroke scales

utilized in the acute stroke setting.

• Highlight rapid stroke scoring systems to identify

large vessel occlusion (LVO).

• Discuss the diagnostic work up and treatment of

acute ischemic stroke.

What is a “Stroke”?

Cerebro – Vascular – Accident

“CVA”

… a disease that affects the arteries leading to and within the brain

“A stroke occurs when a blood vessel that carried oxygen and nutrients to the brain is either blocked by a clot or bursts (or

ruptures).”

No blood / oxygen to the brain tissue = brain cell death

strokeassociation.org

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American Stroke Association

“Impact of Stroke (Stroke statistics)”

• Nearly 800,000 Americans each year. • Someone has a stroke every 40 seconds.• Approx 75% being first time strokes• #5 cause of death in the U.S.• Leading cause of long-term disability • Leading preventable cause of disability• Women > Men• African Americans > any other racial group

http://www.strokeassociation.org/STROKEORG/AboutStroke/Impact-of-Stroke-Stroke-statistics_UCM_310728_Article.jsp#.WKI4L7GZP-Z

June 2016

Types of Strokes• Ischemic (Clots)

• Hemorrhagic (Bleeds)

• Transient Ischemic Attacks (TIA)

• Cryptogenic (Strokes of unknown cause)

Most Common Causes of

AISCerebral thrombosis

• Blood clot that develops at the clogged part of

the vessel

Cerebral embolism

• Blood clot that forms at another location and

float until they reach a cerebral vessel too

narrow to pass.

National Stroke Association. (2010). Explaining Stroke. Retrieved from National Stroke Association: http://www.stroke.org/site/PageServer?pagename=explainingstroke

http://www.strokeassociation.org/STROKEORG/AboutStroke/Impact-of-Stroke-Stroke-statistics_UCM_310728_Article.jsp.WKI4L7GZP-Z

http://www.stroke.org/site/PageServer?pagename=explainingstroke

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• Approx 87% of all strokes

• Obstruction within a

cerebral blood vessel

supplying blood to the

brain.

• Atherosclerosis:

development of fatty

deposits lining the vessel

walls.

Acute Ischemic Stroke (AIS)


http://www.stroke.org/understand-stroke/recognizing-stroke/signs-and-symptoms-stroke

65 y/o female presents to ED with right sided

weakness (both upper and lower), right facial

droop, left sided gaze deviation, unable to follow

commands or speak (global aphasia).

Onset 45 min prior to arrival.

PMHx: Dyslipidemia, HTN

Pertinent Meds: ASA, lisinopril/HCTZ, simvastatin

http://www.stroke.org/understand-stroke/recognizing-stroke/signs-and-symptoms-stroke

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Acute Ischemic Stroke

Clinical Evaluation

NIH Stroke Scale

Rapid Arterial

oCclusion

Evaluation

1a: Level of Consciousness 6a. Motor Leg – Left

6b. Motor Leg - Right

1b: LOC Questions

(month, age)

7. Limb Ataxia

1c: LOC Commands

(Open/close eyes, squeeze/release)

8. Sensory

2. Best Gaze 9. Best Language

(Name item, describe a picture and read

sentences)

3. Visual Fields 10. Dysarthria

(Evaluate speech clarity by patient

repeating listed words)

4. Facial Paresis 11. Extinction and Inattention

(Use info from prior testing to identify

neglect or double simultaneous stimuli

testing)

5a. Motor Arm – Left

5b. Motor Arm - Right

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Score Stroke Severity

1-4 Minor stroke

5-15 Moderate stroke

16-20 Moderate to severe stroke

21-42 Severe stroke

> 16 Moderate – Severe

Stroke

NIHSS > 5 = Indication for

rtPA and/or thrombectomy

Rapid Arterial oCclusion Evaluation

1. Facial Palsy• None present• Mild• Moderate to severe

= 0= 1= 2

2. Arm Motor Function• Normal to Mild • Moderate• Severe

= 0= 1= 2

3. Leg Motor Function• Normal to Mild• Moderate• Severe

= 0= 1= 2

4. Head Gaze Deviation• Absent• Present

= 0= 1

5. Aphasia* (if R side hemiparesis)• Performs both tasks correctly• 1 task correctly• Neither tasks

= 0= 1= 2

6. Agnosia* (if L side hemiparesis)• Recognizes his/her arm and the

impairment• Recognition of either arm or

impairment• No recognition of arm nor

impairment

= 0

= 1

= 2

Rapid Arterial oCclusion Evaluation

Score of >/= 4 has high sensitivity for

large vessel occlusion (LVO)

Presence of Gaze deviation or Global

Aphasia = high likelihood of a LVO

Should divert to comprehensive

stroke center (CSC) for possible

endovascular intervention

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NIH Score =

26

No

Hemorrhage

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Best LevelMultiple RCTs or

meta-analysis

Limited populations evaluated

Single RCT or nonrandomized studies

Lowest levelLimited evidence

Expert opinion

• Protein

• Catalyzes the conversion

of plasminogen to plasmin

which leads to clot

breakdown

• Contraindicated in patient’s

with acute hemorrhage

Antidote = aminocaproic acid

or transexamic acid

“Gold Standard” of treatment of AIS

12 large scale, high quality trials

Meta-analysis of these trials concluded rtPA

significantly increased the odds of being alive and

independent at final follow-up.

Especially in those treated within 3 hours of

symptoms onset.

Treatment effects are time dependent.

Should make every effort to shorten time from stroke

onset to IV rtPAstrokeassociation.org

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ECASS I & ECASS II

ATLANTIS A & ATLANTIS B

N = 821, randomized to either alteplase (418) or placebo

(403)

Average time of alteplase administration, 3 hr 59 min

Higher incidence of ICH in alteplase group

Significantly improved clinical outcomes in patients who

received alteplase

• IV rtPA is recommended for selected patients who may be

treated within 3 hours of ischemic stroke onset (Class 1,

Level of Evidence A).

• Door to needle administration should be within 60 minutes

(Class 1, Level of Evidence A)

• IV rtPA is recommended for administration for eligible patients

who can be treated in the time period of 3 – 4.5 hours (Class

1, Level of Evidence B).

• Blood pressure should be lowered to < 185 / 110 and stable

prior to initiated of rtPA infusion (Class 1, Level of Evidence

B). strokeassociation.org

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Medical Treatment

Inclusion Criteria:

• > 18 years old

• Clinical dx of AIS

• Known time of onset < 3 hours

Exclusion Criteria:

- Contraindications -

• ICH on CT

• Clinical suspicion of SAH

• CT shows multilobar

infarction (hypodensity > 1/3

hemisphere)

• Hx ICH

• Witnessed seizure at stroke

onset

• Pregnancy

Tissue Plasminogen Activator “tPA”

• Known AVM, neoplasm or

aneurysm

• Uncontrolled HTN. SBP > 185 or

DBP > 110 at time of

administration

• Acute bleeding tendencies:

– Platelet count < 100,000

– Received heparin in past 48

hrs w/ elevated PTT

– Current use of

anticoagulation

• Intracranial or spinal surgery,

head trauma or previous stroke

in past 3 months

• Arterial puncture at

noncompressible site w/in 7

days


- Relative Contraindications / Precautions –

• NIHSS > 22 (severe deficit) or < 4 (unless aphasia) (mild

deficit) or rapidly improving symptoms (spontaneous

clearing).

• 14 days post operative or post trauma

• Recent GI or urinary tract hemorrhage (prior 21 days)

• Recent AMI (prior 3 months)

• Post myocardial infarction pericarditis

• Glucose < 50 mg/dl OR > 400 mg/dl

• > 80 years of age

• History of ischemic stroke AND diabetes

• On anticoagulation but INR < 1.7

Exclusion Criteria:

Medical TreatmentTissue Plasminogen Activator “tPA”


What is the tPA window for this

patient?

A. 60 min

B. 6 hours

C. 3 hours

D. 4.5 hours

What is the tPA window for this

patient?

A. 60 min

B. 6 hours

C. 3 hours

D. 4.5 hours

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Is this patient a candidate for tPA?

A. Yes

B. No

Is this patient a candidate for tPA?

A. Yes

B. No

3 mm

5 mm

8 mm

Probability of recanalization

drops with clot length > 3 mm!

(Str

oke

. 2

011;

42:1

775

-177

7.)

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• Endovascular procedure utilizing a stent

retriever placed in the occluded vessel

• Time window expanded to 6 hours (can

extend to 8 hrs in some cases) from

symptoms onset

• Good for those who fail IV-rtPA eligibility

• Basilar artery

• Vertebral artery

• Carotid artery

• Middle cerebral artery

• Anterior cerebral artery

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1. STAT CT Brain without contrast

2. Obtain NIH Stroke Scale and/or FAST

exam

3. Assess eligibility screening for rtPA

4. If NIH > 6, aphasic, or loss of vision,

should obtain STAT CT Head

Angiogram to eval for LVO.

Obtain NIHSS as soon as possible &

attempt to obtain CT and CTA at the

same time

Left M1 Occlusion

CT Head Angio

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Signs & Symptoms of LVO

Left Hemisphere

Speech Impairment or

Lack of Speech

Lack of Comprehension

Left Gaze

Right Facial Droop

Right Sided Weakness


Right Hemisphere

Slurred Speech

Right Gaze

Left Facial Gaze

Left Sided Weakness

Left Sided Neglect

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Abnormal Eye Movements

Nausea, Vomiting or Vertigo

Difficulty Speaking

Decreased Consciousness

Crossed Signs

(ex: left side facial droop and

right sided weakness)


Brainstem

Does our patient appear to have a

LVO?

A. Yes

B. No

Does our patient appear to have a

LVO?

A. Yes

B. No

Notify on call neuro-endovascular team

immediately or arrange STAT transfer to

closest comprehensive stroke center

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Purpose: Prove the beneficial effects of intraarterial therapy on functional

outcome.

Methods: RCT to either intraarterial treatment plus usual care or usual care

alone.

Eligibility: Proximal arterial occlusion in the anterior cerebral circulation

confirmed on vessel imaging and treatment completed within 6 hours.

N = 500 (233 assigned to intraarterial treatment and 267 to usual care

alone)

Results: Intraarterial treatment administered within 6 hours after stroke

onset was effective and safe.

Purpose: Evaluate efficacy of standard of care vs standard of care plus

thrombectomy

Method: RCT

N = 238 (120 standard care plus thrombectomy, 118 in standard of care

alone)

Results: Rapid endovascular treatment improved functional outcomes

and reduced mortality.

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LVO LVO LVO + mCTA LVO + Perfusion LVO + PerfusionADVANCED IMAGING SELECTION LVO + Perfusion

AHA / ASA 2015 Update:

• Patients eligible for intravenous r-tPA should receive

intravenous r-tPA even if endovascular treatments are

being considered (Class I; Level of Evidence A).

• In carefully selected patients with anterior circulation

occlusion who have contraindications to intravenous r-

tPA, endovascular therapy with stent retrievers

completed within 6 hours of stroke onset is reasonable

(Class IIa; Level of Evidence C).


• Patients should receive endovascular therapy with a stent

retriever if they meet all the following criteria (Class I; Level of

Evidence A). (New recommendation):

– (a) prestroke mRS score 0 to 1

– (b) AIS receiving IV r-tPA within 4.5 hours of onset according

to guidelines from professional medical societies

– (c) causative occlusion of the internal carotid artery or

proximal MCA (M1)

– (d) age ≥18 years

– (e) NIHSS score of ≥6

– (f) ASPECTS of ≥6, and

– (g) treatment can be initiated (groin puncture) within 6 hours

of symptom onset

AHA / ASA 2015 Update:


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Successful Recannulation!!!

TICI Criteria for M1 Occlusion

Grade 0 No antegrade flow beyond occlusion

Grade 1 Open beyond obstruction but not distal

Grade 2a < 50% MCA circulation

Grade 2b > 50% MCA circulation

Grade 3 Full recanalization

***Grade 2b and 3 have best neurologic outcomes***

NIHSS = 12 within 24 hours (NIHSS 26

initially)

Discharged to inpatient rehab in 5 days

Follow-up modified Rankin Scale = 2

(able to handle daily affairs and with

minimal assistance)

Great Job!!!

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B-0 DWIB-1000

ADC

• “Wake up Stroke”

• Clinical exam out of proportion to hypodensity on CT

• Out of 4.5 hour window but stuttering symptoms

Blood Pressure Goals

Post rtTPA + Thrombectomy

• Depends mostly on the endovascular team findings and TICI score

Post rtPA Only

• SBP < 185, DBP < 110

No pharmacologic or mechanical intervention

• SBP < 200+ (permissive hypertension)

Post AIS Work-Up

Vascular Imaging

Lipid Panel

HgbA1C

Transthoracic Echocardiogram

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Key Points

• Memorize or have access to a quick stroke

screening tool (ie. Cincinnati Stroke Scale)

• Obtain STAT CT Brain

• Assess eligibility for rtPA and administer as soon

as possible. Goal door to needle 1 hour!

• If NIHSS > 6, obtain STAT CT Head Angio to

eval for LVO.

• If LVO, arrange for immediate mechanical

thrombectomy.

• rtPA approval window up to 4.5 hours

• Mechanical thrombectomy window up to 6-8

hours

Thank you so much for

your time!

Mindy Mason, MSN, RN, ACNP-BC

[email protected]

PowerPoint Presentation€¦ · • If NIHSS > 6, obtain STAT CT Head Angio to eval for LVO. • If LVO, arrange for immediate mechanical thrombectomy. • rtPA approval window up

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