Stroke Update - rcplondon.ac.uk

Stroke Update

2017-06 GIM SpR Teaching

Dr Amit Mistri

Consultant in Stroke Medicine

Learning objectives

This session aims to improve knowledge on: • GIM SpR as the Stroke oncall SpR

• ED process & responsibilities • GIM SpR role(s)

• Hyperacute interventions in acute stroke • Thrombolysis • Thrombectomy

• Medications post stroke • Risk factor control in stroke • Thresholds and targets

• AF management for stroke prevention • Objective estimation of risk • General medical requirements

ED presentation

• 60 year old gentleman

• Witnessed onset of right side weakness @1400

• Pre-alerted as FAST + by EMAS

• RAP call from ED to alert the Stroke team

• Hypertensive on Ramipril

Questions

• Who has primary responsibility for this patient?

• What is the role for ED?

• What is the role for the GIM SpR (holding the Stroke bleep)?

• What is the role of the Stroke Consultant on call?

Responsibility

• All FAST + pre-alerts automatically fall under the remit of the Stroke Team (irrespective of initial or eventual diagnosis)

• The Stroke team (GIM SpR out of hours) will assess, diagnose, arrange initial investigation and establish where the patient needs to go

• There is no role for ED, unless critically unwell requiring resuscitation etc (uncommon)

FAST test

PPV 89% NPV 73%

Paramedic acute stroke

FAST +

Acute Stroke

Major disabling

Stroke Unit

Minor non-disabling

TIA clinic

Not Acute stroke

TIA

TIA clinic

Other medical

AMU

Other non-sinister

Discharge +/- follow up

Minor stroke?

ED strokes

• ED recognise an acute stroke

• ROSIER tool recommended • Extension of FAST tool

• ROSIER + picks up vast majority of acute strokes

• If ROSIER - & clinical suspicion persists, then Reg2Reg discussion

ROSIER

PPV 90% NPV 88%

Stroke ED assessment proforma for adults

Click picture to open full ED Pathway

Stroke ED assessment proforma for adults

ED acute stroke

ROSIER +

Acute Stroke

Major disabling

Stroke Unit

Minor non-disabling

TIA clinic

Not Acute stroke

TIA

TIA clinic

Other medical

AMU

Other non-sinister

Discharge +/- follow up

GIM SpR considerations

• Is it a stroke?

• Is medical stabilisation required?

• Is there an indication for urgent CT scan?

• Is thrombolysis a possibility?

• Is thrombectomy (clot extraction) a possibility?

• Is there a reason to “not go to ASU”?

Is it a stroke?

• Focal neurological deficit!!

• OCSP classification

• NIHSS neurological assessment

Patient Paramedic ED ASU Stroke Rehab.

OP Clinic

TIA clinic

OCSP Aetiology Clinical Presentation Relevance

TACS total anterior circulation stroke

20%

Proximal 0cclusion (ICA or MCA), large volume infarct Superficial + deep territories

►Contralateral hemiparesis (+/- hemihypoaesthesia) ►Contralateral heminaopia ►Higher cerebral dysfunction (cortical signs:

dysphasia, dyspraxia, inattention)

High mortality

PACS partial anterior circulation stroke

35%

Occlusion of MCA branch Restricted infarct

2 of above 3 OR Restricted motor deficit (face OR arm OR leg only) OR isolated cortical signs

High early recurrence rate

LACS lacunar stroke

20%

Single perforating artery Basal ganglia/pons

Pure motor, pure sensory, sensorimotor, ataxic hemiparesis

Silent, underdiagnosed

POCS posterior circulation stroke

25%

Brainstem, cerebellar or occipital involvement

Complex presentation Thrombosis

Bamford et al Classification and natural history of clinically identifiable subtypes of cerebral infarction Lancet 337; 8756: 1521

OCSP based prognostic estimate

Prognosis more favourable than other clinical sub-types:

1 year outcome based on clinical subtype

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

All

ischaemic

stroke

TACS PACS LACS POCS

Independent

Dependent

Dead

Stroke “mimics” Things that look like a stroke

• Brain problems – tumour, multiple sclerosis, traumatic bleeds outside the brain

• Spinal cord problems – tumour, infection, trauma

• Peripheral nerve problems – diabetic nerve damage

• Other neurological conditions migraine with stroke-like presentation,

Bells Palsy, Transient memory loss etc

• Functional neurological syndrome – looks like a stroke, but

specialists can diagnose using examination, brain scan and symptom progression.

• Metabolic problems – changes in blood levels of glucose, sodium etc

Is medical stabilisation required?

• Resp distress

• Fast AF

• Sepsis

• ACS

Next-on-table CT scan

• Neurological deficit onset within previous 4 hours

• Indication for thrombolysis/thrombectomy or early anticoagulation treatment

• On anticoagulant medication (e.g. VKA; NOAC/DOAC or heparin)

• Drowsiness GCS ≤ 13 and/or NIHSS 1a ≥ 1

• Known bleeding diathesis

• Unexplained progressive / fluctuating symptoms after onset

• Severe headache at onset

• Papilloedema, neck stiffness or fever

What a scan is not for?

• NOT to rule out infarct

~80% of early scans are normal

• NOT prognostic Clinical assessment OCSP far better at prognosis Adjunctive value if obvious bleed or major infarct

• Should GIM SpRs interpret CT Brains?

• Radiology SpR available 24-7 • Consultant can see image at home if needed • Primer on Brain imaging in subsequent talk

Is thrombolysis a possibility?

TIME IS BRAIN earlier presentation does not mean you have more time,

it means that you have

more potential to limit brain damage

SUSPECTED STROKE

Not for lysis

Standard management

Uncertain

Ask Consultant

For lysis

Ask Consultant

Practical issues

• Cannula & bloods needed (JD) • Bed needed (Stroke Sp N) • Blood results not necessarily required • Call Consultant for final lysis decision

• Weight based dosing - patient should be weighed on entering

ED, if not – use prior known weight or estimated weight (for bolus)

• Alteplase dosing chart available • Bolus without delay (ideally in ED, after CT & Cons approval) • 1h follow up infusion on ASU

6.3 Intravenous thrombolysis

• Robust UHL Guidelines

6.3.2 Exclusion criteria (1)

6.3.2 Exclusion criteria (2)

Thrombolysis consent

• Verbal, but documented - Patient or proxy or in best interests

• “Brain scan shows no bleeding, and the clinical presentation suggests a clot causing blockage”

• “We recommend medication to try and dissolve this clot and minimise brain damage and associated disability”

• “This treatment can have side effects…”

For every 20 people treated

6 are less disabled

13

are unchanged with respect to disability

1

is worse off because of a major bleeding

complication

IP strokes

• Consistent evidence of poorer management & missed thrombolysis opportunities

• More likely to have contraindication to lysis e.g. on full dose heparin, recent operation etc

• PROCESS • Other hospital > blue light to LRI ED (for CTH-RAP team)

(unless over-riding clinical care need e.g. post surgical)

• LRI wards > avoid CT delays

Which statements are true?

• Once thrombolysed

– BP criteria are relaxed

– Respiratory distress is almost always due to anaphylaxis

– Anaphylaxis is more likely because this patient is on an ACE inhibitor

– Tongue swelling without rash/wheeze indicates early anaphylaxis

– Brain bleeding occurs in ~5%

Post thrombolysis care

• Bleed risk goes down with time

• Standard ASU protocol for monitoring

• Keep SBP<180

• If neurological deterioration (GCS, NIH) • Medical – Rx cause

• Neurological – repeat CTH

• Stop infusion?

• Is reversal required?

What is thrombectomy?

• Mechanical Thrombectomy (MT) or clot extraction

• Potent effect: NNT ~ 5 to improve outcome

• Not universally available, at present

• DoH commitment to fund this…!!!

• Available in Nottingham / Birmingham ad hoc individual patient basis during “working hours”

• Pre-requisites • Must involve Stroke Consultant

• Needs CT Angio – with proximal MCA occlusion

• <6h from onset

“Not for ASU” patient

• Indication for neurosurgery if agreed, ideally direct to QMC may need interim ITU or Stroke Bed

• Other over-riding clinical need • Ventilation in ITU or NIV in ACB

• Multi-system disease in ITU

• Clear indication for surgical intervention

• Acute cardiac condition requiring GH input

5 days later

• Medically stable, EWS 0

• Weakness minimal, and mobilising on ward

• ECG – sinus, pulse regular

• Had a Carotid Doppler undertaken

5 days later….

• Management plan – which statements are true?

• Significant carotid stenosis is narrowing >70%

• Echocardiogram is recommended for all patients

• Vascular surgeons are unlikely to intervene after stroke

• High alcohol intake is not a risk factor for ischaemic stroke

• An ECG is frequently missed out

• Prophylactic heparin should be used for all patients to prevent VTE

25 days later….

• Mobilising independently

• Independent with ADLs

• BP well controlled

• No evidence of AF

• Aiming to go home with wife

25 days later….

• Management plan – which statements are true?

• The 3 key groups of medications required are – Antithrombotics, Antihypertensives and Antihyperlipidaemics

• Driving: patient can return to driving on day 30

• Patients can be provided therapy at home

• A common cause of recurrent stroke is medication non-compliance

• There should be a low threshold for undertaking prolonged cardiac monitoring

Primary prevention

• >10% 10 year CV risk

• Aggressive therapy/targets - not generally advised

Antiplatelet

• Aspirin low-dose no longer advised

• A/C for AF (CHADSVaSC)

Antihypertensive

• NICE/BHS optimal target <140/85

• QOF: BP<150/90

Lipid modifying agent

• Targets TC<4.0, LDL<2.0

• QOF: TC<5.0

Secondary prevention

• No CV risk calculation – high risk by definition

• Aggressive therapy/targets advised

Antiplatelet

• Clopidogrel

• Aspirin+Dipyrid.

• Aspirin

• A/C for AF

Antihypertensive

• NICE/BHS optimal target with TOD <130/80

• NICE age>75: <140/90

• QOF: BP<150/90

Lipid modifying agent

• Targets TC<4.0, LDL<2.0

• QOF: TC<5.0

RCP Clinical Guidelines for Stroke 4th Edition

Stroke “mimics” Things that look like a stroke

• Brain problems – tumour, multiple sclerosis, traumatic bleeds outside the brain

• Spinal cord problems – tumour, infection, trauma

• Peripheral nerve problems – diabetic nerve damage

• Other neurological conditions decompensation of previous stroke

deficit; migraine with stroke-like presentation, Bells Palsy, transient memory loss etc

• Functional neurological syndrome – looks like a stroke, but clear

discrepancy between objective and functional assessments, Hoover’s sign +

• Metabolic problems – changes in blood levels of glucose, sodium etc

Outpatient review @3m

• No recurrence of neurological symptoms

• Virtually complete recovery

• Taking Clopidogrel, Amlodipine 10, Atorva 40 • Can he drive?

• Can he drink?

• Exercise recommendations?

AF & ANTICOAGULATION Co-Chair of Anticoagulation Task & Finish Group

AF indicates a preventable catastrophe

• Do a risk assessment promptly • CHADSVASC – annual rate of embolic stroke • HASBLED – annual rate of major bleeding (on A/C) • Prior bleeding/predisposition to bleeding

• Aim to identify those that will not benefit • Embolic risk too low (CHADSVASC 0, & 1 in women) • Bleeding risk permanently high (irremediable structural

lesion) – if remediable, then r/v anticoagulation again • Terminal stage of life?!

• Ideally same day ECG & A/C plan • Specialist opinion if needed

Objective estimation of risk

chadsvasc.org

CHA2DS2VASc Score can only go up HAS-BLED

Modifiable i.e. score can go down (e.g. if SBP treated to <160)

What A/C are available?

• Apixaban

• Dabigatran

• Edoxaban

• Rivaroxaban

• Warfarin

All are GREEN for

ATRIAL FIBRILLATION & STROKE PREVENTION

<Primary & Secondary care>

SHARED CARE AGREEMENT for

VENOUS THROMBO-EMBOLISM

<Secondary care initiated>

DOAC specific issues

• DO NOT USE – With metallic valves

– With mitral stenosis

– CrCl<30

– Bleeding that contraindicates warfarin!

– Poor medication compliance

• ECHO for AF – Not routinely required if no murmur

– If requesting Echo, do not delay anticoagulation initiation

– Review Echo results (in case DOAC contraindicated)

DOAC monitoring Frequency of review in line with CKD guidance

Content of review Thrombosis Canada Ann Intern Med 2015; 163: 382-385

CrCl>60 CrCl<~60 CrCl<~45

12 monthly 6 monthly 3 monthly

DON’T USE LOW DOSE Apix/Riva/Edox WITH THE INTENTION TO REDUCE BLEEDING RISK BECAUSE YOU DON’T GET STROKE PREVENTION, IF DOSE REDUCED INAPPROPRIATELY

• Adherence assessment A

• Bleeding screen B

• CrCl calculation C

• Drug interactions check (BNF) D

• Examination: BP E • Final assessment (continue,

change dose or A/C, stop)

• Follow up F

A/C related bleeds

• Life threatening, high mortality • In AF populations, brain infarcts (not anticoagulated)

are 5-10 times commoner than ICH (with A/C for AF)

• Hypertension management • Aim for SBP<140 in all ICH inpatients • Longer term aim for good BP control SBP<130-140

• Management • Local measures • Resuscitation • Antidotes now available on ED shop floor, soon to be

measured as a Door-To-Needle metric

UHL Policy - DOACs

ADMISSION AND DISCHARGE OF PATIENTS ON ANTICOAGULATION

PATIENT ADMITTED TO UHL

WITHIN 24 HOURS OF ADMISSION, WARD SENDS REFERRAL TO ANTI-COAG IN-REACH TEAM FOR SUPPORT

(WHERE CLINICALLY APPROPRIATE)

PATIENT RECIEVES ANTI-COAG MANAGEMENT PLAN (WARDS SUPPORTED BY IN-REACH TEAM AS CLINICALLY APPROPRIATE)

NON-COMPLEX PATIENT DISCHARGED TO PRIMARY CARE

NEW DISCHARGE LETTER/TEMPLATE SENT TO PRACTICE VIA ICE

UHL TO DOSE FOR 4 WORKING DAYS

EXCEPTIONS: • SHORT STAY ADMISSIONS < 24 HOURS

• UNSTABLE INRs – NOT DISCHARGED OVER WEEKEND

PRIMARY CARE TO TAKE OVER PATIENT CARE AT DISCHARGE

(DOSED FOR 4 WORKING DAYS)

ANTI-COAG IN-REACH TEAM SUPPORT HELPLINE TEL: XXXXXXXXXXXXXXXXXX

(WILL RESPOND IN XXXXXX)

ADVICE AND GUIDANCE (NON URGENT) TEL: XXXXXXXXXXXXXXXXXXX

CONSULTANT CONNECT (URGENT) TEL: XXXXXXXXXXXXXX

ON CALL CONSULTANT HAEMATOLOGY TEAM TEL: XXXXXXXXXXXXX IF PATIENT BECOMES COMPLEX – ROUTINE REFERRAL

COMPLEX PATIENTS TO

REMAIN UNDER CARE OF UHL

SUPPORTING INFORMATION

NEUROLOGICAL

1. Brain oedema

/swelling 10-20% MCA strokes 17-54% cerebellar

2. Secondary

bleeding 30-40%

3. Recurrent

stroke 1w 10%; 1m 2-3% Annual 5%

4. Seizures / fits

Early 2-23%; late 3-67%

5. Delirium 13-48%

6. Central post-

stroke pain

7. Headache

Sentinel 43-60% Onset 25-30% After 14-27%

8. Sleep disorders

10-50%

MEDICAL 1. Infection

2. VTE (HAT)

3. Pressure Ulcers

4. Falls

5. Musculoskeletal – Joint dislocations, pain

PSYCHOSOCIAL

1. Psychological

issues

2. Dignity

InSITE – Stroke Services UHL Guidelines for Stroke & TIA Stroke – ED Assessment Proforma for adults

Clinical Medicine Expert recommendations

▪ NICE Guidelines for Acute Stroke & TIA

▪ RCP Guidelines for Stroke (more on longer term management)

▪ NICE Guidelines for AF