1 Case 10 Acute Stroke © 2001 American Heart Association

2 Case 10: Acute Ischemic Stroke Learning Objectives At the end of this case the participant will be able to t Recognize signs and symptoms of stroke t Discuss major principles of prehospital and ED stroke care t Understand the potential use of thrombolytics for selected patients with acute ischemic stroke

3 Phase 1: Prehospital Learning Objectives t Recognize stroke signs and symptoms t Be able to use either the Cincinnati Prehospital Stroke Scale or Los Angeles Prehospital Stroke Screen t Appreciate importance of rapid transport to ED t Appreciate importance of notifying ED before arrival t Know the differences between ischemic and hemorrhagic stroke

4 A Woman Has Collapsed… Case Presentation 6:30 PM : You are sent with other paramedics to a shopping mall, where a woman has collapsed. 6:35 PM : When you arrive you find an African- American woman sitting on a bench. She is confused but responds to verbal stimuli. What clinical events could explain her condition?

5 Building a Differential Diagnosis Initial vital signs, clinical signs, and history t Adequate airway and ventilation t Normal heart rate, regular rhythm, adequate perfusion t No ischemic chest pain t Complains of dysarthria t Complains of right-sided paralysis t History of poorly controlled hypertension 1. What additional information do you need? 2. What is your differential diagnosis now?

6 Different Causes of Collapse and Focal Neurologic Deficits t Hemorrhagic stroke t Ischemic stroke t Craniocerebral/ cervical trauma t Hypertensive encephalopathy t Intracranial mass t Meningitis/encephalitis t Seizure t Migraine t Metabolic conditions (including hypoglycemia or hyperglycemia, drug overdose) What further information would be helpful?

7 Case Development The woman’s daughter reports that t Her mother felt fine while shopping t Suddenly her arm “felt funny” t She slumped gently to the floor t There was no loss of consciousness, no head trauma t She never complained of a headache t There are no acute signs or a past history of seizures, diabetes, heart disease, palpitations What additional assessments are needed now?

8 Cincinnati Prehospital Stroke Scale 3 Components: t Facial droop (ask patient to show teeth and smile) t Arm drift (ask patient to extend arms, palms down, with eyes closed) t Speech (ask patient to say “You can’t teach an old dog new tricks”) Look for abnormalities.

9 Details of Facial Droop

10 Details of Arm Drift

11 Immediate assessment: <10 minutes from arrival Assess ABCs, vital signs Provide oxygen by nasal cannula Obtain IV access; obtain blood samples (CBC, electolytes, coagulation studies) Check blood sugar; treat if indicated Obtain 12-lead ECG, check for arrhythmias Perform general neurological screening assessment Alert Stroke Team: neurologist, radiologist, CT technician Immediate neurological assessment: <25 minutes from arrival Review patient history Establish onset (<3 hours required for fibrinolytics) Perform physical examination Perform neurological examination: Determine level of consciousness ( Glasgow Coma Scale ) Determine level of stroke severity ( NIH Stroke Scale or Hunt and Hess Scale ) Order urgent noncontrast CT scan (door-to–CT scan performed: goal <25 minutes from arrival) Read CT scan (door-to–CT read: goal <45 minutes from arrival) Perform lateral cervical spine x-ray (if patient comatose/history of trauma) Acute Stroke Algorithm EMS assessments and actions Immediate assessments performed by EMS personnel include Cincinnati Prehospital Stroke Scale (includes difficulty speaking, arm weakness, facial droop) Los Angeles Prehospital Stroke Screen Alert hospital to possible stroke patient Rapid transport to hospital Suspected Stroke Detection Dispatch Delivery Door

12 Case Continues Examination in the shopping mall: t Patient demonstrates right-sided facial droop t Right-arm weakness t Slurred speech What do you conclude from this examination? What further information is critical?

13 Case Continues Daughter states t Mother’s symptoms developed shortly before call to 911 t She is unsure of exact time of symptom onset, but with more effort she recalls that She and her mother walked past an electronics store Her mother stopped to watch the weather report on the local news The weather report always airs at 6:20 PM Why is this time-of-onset information critical? What are assessment and management priorities during transportation?

14 Critical Actions: Possible Stroke Patient in Prehospital Setting Prehospital Critical Actions t Assess and support cardiorespiratory function t Assess and support blood glucose t Assess and support oxygenation and ventilation t Assess neurologic function t Determine precise time of symptom onset t Determine essential medical information t Provide rapid transport to ED t Notify ED that a possible stroke patient is en route

15 Case Continues 6:45 PM : EMS unit contacts ED (symptoms + 25 min) t 63-year-old African-American woman collapsed at shopping mall t Possible stroke victim: Cincinnati Prehospital Stroke Scale = Right facial droop; right-arm weakness; dysarthria t Vital signs: BP = elevated: 198/120 mm Hg; airway, ventilation adequate t Information given to head nurse, triage nurse, ED physician t ED physician alerts CT scan, neurology 7:00 PM : EMS at door of ED (symptoms + 40 min) t Triage nurse waits at door; patient is triaged to critical care area t Triage nurse notifies physician that possible fibrinolytic candidate has arrived What are initial ED care priorities?

16 Phase 2: Emergency Department Learning Objectives At the end of this case participants will be able to discuss t Importance of rapid triage and early CT for stroke victims t Use of National Institutes of Health Stroke Scale (NIHSS) t Guidelines for managing hypertension in stroke patients t Clinical differences between ischemic and hemorrhagic stroke t Treatment differences between ischemic and hemorrhagic stroke

17 Key Evaluation Targets for Stroke Patient: Potential Fibrinolytic Candidate? Door-to–doctor first sees patient…….…………10min Door-to–CT completed…….…………………..25min Door-to–CT read...…………..…………………45min Door-to–fibrinolytic therapy starts…………….. 60min Neurologic expertise available*…..……………15min Neurosurgical expertise available* …………… 2hours Admitted to monitored bed..……...…………… 3hours *By phone or in person 1. What neurologic assessments are now appropriate? 2. What is role of NIHSS? Maximum Intervals Recommended by NINDS

18 Immediate General Assessment Assessment Goal: in first 10 minutes t Assess ABCs, vital signs t Provide oxygen by nasal cannula t Obtain IV access; obtain blood samples (CBC, ’lytes, coagulation studies) t Obtain 12-lead ECG, check rhythm, place on monitor t Check blood sugar; treat if indicated t Alert Stroke Team: neurologist, radiologist, CT technician t Perform general neurologic screening assessment

19 Immediate Neurologic Assessment Assessment Goal: in first 25 minutes t Review patient history t Establish symptom onset (<3 hours required for fibrinolytics) t Perform physical examination Perform neurologic exam Determine level of consciousness (Glasgow Coma Scale) Determine level of stroke severity (NIHSS or Hunt and Hess Scale) t Order urgent noncontrast CT scan (door-to–CT scan performed: goal <25 min from arrival) t Read CT scan (door-to–CT read: goal <45 min from arrival) t Perform lateral cervical spine x-ray (if patient comatose/trauma history) What is the next step?

20 Case Continues Patient is transported to CT: review BPs: BP in the field = 198/120 mm Hg BP on ED arrival = 190/110 mm Hg BP during CT scan = 190/100 mm Hg 1. Does this patient require treatment for high BPs? 2. If “yes,” then how? 3. For acute stroke patients, when is aggressive BP management indicated?

21 Acute Stroke Patients: Indications for Antihypertensive Therapy In general: t Consider: absolute level of BP? If BP: >185/>110 mm Hg = fibrinolytic therapy contraindicated t Consider: other than BP, is patient candidate for fibrinolytics? If patient is candidate for fibrinolytics: treat initial BP >185/>110 mm Hg t Consider: response to initial efforts to lower BP in ED? If treatment brings BP down to <185/110 mm Hg: give fibrinolytics t Consider: ischemic vs hemorrhagic stroke? Treat BP in the / mm Hg range the same The obvious: no fibrinolytics for hemorrhagic stroke

22 Treatment of High BP in Acute Stroke Patients BP Level >185/>110 mm Hg During/after fibrinolytic treatment BP may rise: DBP >140 mm Hg >230/ mm Hg / mm Hg Fibrinolytic Candidate Nitropaste or labetalol IV if BP remains elevated: no fibrinolytics Nitroprusside infusion Labetalol, then prn nitroprusside Labetalol Not a Fibrinolytic Candidate No acute therapy indicated Nitroprusside infusion Labetalol Acute therapy only if hypertensive urgency also present

23 Case Continues 7:40 PM: Patient returns from CT scan (symptom onset +1 hr:20 min) t Nurse: “BP is 190/115 mm Hg ECC Handbook says treat this BP before giving fibrinolytics.” t 2000 ECC Handbook: BP = >185/>110 mm Hg: use nitropaste or labetalol t Labetalol 10 mg IV administered (repeated 10 min later) t BP = 175/100 mm Hg 1. What is CT scan most likely to show? 2. How would each of these findings affect therapy? a. Hypodense area? b. Hyperdense area? c. Diffuse hypodense areas?

24 What Pathology Does This Scan Show? Scan A

25 Scan A What Pathology Does This Scan Show? Hypodense area: Ischemic area with edema, swelling Indicates >3 hours old No fibrinolytics! Left Right

26 What Pathology Does This Scan Show? Scan B

27 What Pathology Does This Scan Show? Scan B (White areas indicate hyperdensity = blood) Large left frontal intracerebral hemorrhage. I ntraventricular bleeding is also present No fibrinolytics! Left Right

28 What Pathology Does This Scan Show? Scan C

29 What Pathology Does This Scan Show? Scan C Acute subarachnoid hemorrhage Diffuse areas of white (hyperdense) images Blood visible in ventricles and multiple areas on surface of brain

30 Phase 3: Fibrinolytic Therapy Learning Objectives At the end of Phase 3 participants will be able to t Discuss inclusion and exclusion criteria for fibrinolytic therapy for acute stroke patients t Discuss potential benefits and complications of fibrinolytic therapy for acute ischemic stroke

31 Fibrinolytic Therapy: Yes/No Checklist Inclusion Criteria (all “Yes” boxes must be checked before fibrinolytics are given) Yes  Age 18 years or older  Clinical diagnosis of ischemic stroke causing a measurable neurologic deficit  Time of symptom onset well established to be <180 minutes before treatment would begin

32 Fibrinolytic Therapy: Yes/No Checklist Exclusion Criteria (all “No” boxes must be checked before fibrinolytics are given): No  Evidence of intracranial hemorrhage on noncontrast head CT  Only minor or rapidly improving stroke symptoms  High suspicion of subarachnoid hemorrhage even if CT is normal  Active internal bleeding (eg, gastrointestinal bleeding or urinary bleeding within last 21 days)  Known bleeding diathesis, including but not limited to — Platelet count < mm 3 — Patients who received heparin in last 48 hours; have elevated PTT — Recent anticoagulant use (eg, coumadin); have elevated PT

33 Fibrinolytic Therapy: Yes/No Checklist Exclusion Criteria (cont’d) (all “No” boxes must be checked before fibrinolytics are given): No  <3 mo ago: intracranial surgery, head trauma, previous stroke  <14 days ago: major surgery or serious trauma  <7 days ago: lumbar puncture  Recent arterial puncture at noncompressible site  History of intracranial hemorrhage, AV malformation, or aneurysm  Witnessed seizure at start of stroke  Recent acute myocardial infarction  SBP >185 mm Hg/DBP >110 mm Hg; confirmed several times  BP must be treated aggressively to bring within these limits

34 Case Continues 7:50 PM : CT scan = “normal”  “probable acute ischemic stroke” (symptom onset + 1 hr:30 min) t Look for CT findings that may exclude patient: are any observed? t Repeat neurologic exam: do deficits vary? improve rapidly? t Review fibrinolytic exclusions: do any match patient? t Review clinical data: is symptom onset now >3 hours? t Consider treatment options; potential for benefit vs harm t Discuss with patient and family 30% Likelihood of improvement to minimal or no disability Increase in brain hemorrhage (0.6% to 6.4%) No increase in mortality

35 Stroke Victims: General Treatment 1 t Maintain normal BP (mean arterial pressure 90 to 100 mm Hg) t Titrate fluids and vasoactive agents as needed t Maintain adequate ventilation (arterial PCO 2 30 to 35 mm Hg) t Maintain moderate hypoxia (arterial PO 2 >100 mm Hg) t Use lowest positive end-expiratory pressure possible t Keep arterial pH 7.3 to 7.5 t Immobilize (neuromuscular paralysis) as needed t Sedate as needed (morphine or diazepam) as needed t Anticonvulsants (eg, diazepam, phenytoin, or barbiturates as needed)

36 Stroke Victims: General Treatment 2 t Correct blood abnormalities: ’crit, ’lytes, osmolality, glucose t Give glucose if hypoglycemic t Give insulin if hyperglycemic (>300 mg%) t Give thiamine (100 mg) if malnourished or alcoholic t Give osmotherapy (mannitol or glycerol) as needed for Monitored intracranial pressure elevation or Secondary neurologic deterioration t Avoid hypotonic fluids; avoid excessive fluid t Keep temperature normal (“allow” low temp; “treat” high temp) t Start nutritional support by 48 hours

37 Critical Case Variation: Hemorrhagic Stroke and Clinical Decline 7:40 PM (symptom onset + 1 hr:20 min) t Patient returns to ED after CT scan t She is markedly more lethargic t She has shallow respirations t Audible upper airway obstruction 1. What therapy should be instituted? 2. What information is helpful at this point?

38 Case Continues (Critical Variation) 7:50 PM (symptom onset + 1 hr:30 min) t CT scan = left basal ganglia hemorrhage t Measures 40 mL with mass effect t No extension into intraventricles t Patient’s BP = 220/125 mm Hg What options for therapy are available?

39 Case Continues 8:00 PM (symptom onset + 1 hr:40 min ) Initiate actions for acute hemorrhage t Consult neurosurgeon t Reverse any anticoagulants t Reverse any bleeding disorder t Monitor neurologic condition t Treat hypertension in awake patients t Lower BP: labetalol or nitroglycerin paste Should any other therapy be provided?

40 Case 10: Acute Stroke Summary The “era of reperfusion,” starring new fibrinolytic treatments, has revolutionized the treatment of ACS patients. This has not yet happened for acute stroke patients. The Stroke Chain of Survival, if aggressively applied in every community, has great potential to diminish the devastation of cerebrovascular disease. The Stroke Chain of Survival Detection Dispatch Delivery Door Data Decision Drug