Acute Care of Ischemic Stroke Rafid Mustafa, MS-IV rmustafa@iupui.edu August 9, 2016

Disclosures None I wasn’t even able to get funding for food tonight

Let’s start with a case… 56 yo M, smoker, presents to the ED at 10am… Went to work that morning ~8am with no issues ~9 am coworkers notice that pt has trouble speaking… can’t move right side of body They call 911, EMS personnel diagnose w/ acute stroke and bring him to Methodist Comprehensive Stroke Center In the ED: BP 168/72, HR 84 regular, RR 18, Satting well, no fever No headache, CP, or SOB Basic Neuro Exam reveals an expressive aphasia and complete immobility of left upper and lower extremities. Otherwise WNL. Not on warfarin or other antithrombotic/antiplatelet agents STAT Head CT (non-contrast)  wnl At this point, pt has been in the ED for 20 minutes, ~1 hour 20 minutes post event…

Next Steps?

Stroke AKA cerebrovascular accident Simply when poor blood flow to the brain leads to cell death Neurologic deficit must be >24 hrs (otherwise TIA) Ischemic (~90%) vs Hemorrhagic (~10%) 5th leading cause of death, 1 in every 20 deaths in the United States Etiology: Artery-artery embolism Cardioembolic Small vessel disease (lacunar) Cryptogenic

Stroke Management: Pre-Hospitalization

Pre-hospitalization Stroke education in the community is key! Only ~3% of stroke patients receive thrombolytic therapy because patients often present outside the treatment window Recent efforts are focusing on increasing proportion of pts able to receive IV tPA Ambulance CT scanners Well-trained EMS personnel Neurologists/Radiologists via tele-stroke tPA before the hospital!

Stroke Management: EMERGENCY EVALUATION

Emergency Evaluation Paramedics know what they’re doing Goal is to get patients to a primary stroke center In the ED, rapidly confirm stroke symptoms and establish the last known normal time Stroke order set: Coag studies, CBC, NC Head CT, and EKG (… +CT angiogram) Watch Blood Pressure <185/110 before giving IV tPA <220/110 if no IV tPA (Permissive Hypertension) Sometimes that means bypassing non-stroke centers even if they’re closer

Emergency Evaluation Neurologic Exam: NIHSS (National Institutes of Health Stroke Scale) Objective quantification of stroke impairment Has predictive value for eventual outcomes 11 items, with scores between 0-4 (total max 42) Baseline NIHSS score greater than 16 indicates a strong probability of patient death or severe disability, while a baseline NIHSS score less than 6 indicates a strong probability of a good recovery. On average, an increase of 1 point in a patient’s NIHSS score decreases the likelihood of an excellent outcome by 17%.

Emergency Evaluation Noncontrast Head CT Primarily to exclude intracerebral hemorrhage May also reveal early ischemic signs such as loss of gray-white matter differentiation, sulcal effacement, or a hyperdense vessel sign. Alberta Stroke Program Early CT score (ASPECTS) study Prospective study, 203 stroke patients treated with tPA within 3 hrs of onset 10 point pretreatment CT scan scoring system used to predict pt outcomes

Stroke Management: ACUTE THERAPY

Acute Therapy: IV tPA NINDS (National Institute of Neurological Disorders and Stroke) trial Improved outcome at 3 months in 33% of patients Symptomatic ICH in 6.4% of patients (no difference in mortality) For every 15-min reduction in door-to-needle time, a 5% improvement of in-hospital mortality is realized FDA approved for 3 hour window NOT FDA approved for 3-4.5 hrs, but is recommended European Cooperative Acute Stroke Study III (ECASS III) trial Consent is important No benefit beyond 4.5 hrs

Acute Therapy: IV tPA

Acute Therapy: IV tPA If patient develops new neurologic symptoms after tPA is initiated Stop the infusion Repeat HCT If ICH found, initiate fresh frozen plasma Also consider cryoprecipitate and aminocaproic acid May need to consult neurosurgery

Acute Therapy: Endovascular tPA success is limited in large vessel occlusions of ICA, proximal MCA, and basilar artery This led to exploration of endovascular techniques Initial studies (Intra-arterial Versus Systemic Thrombolysis for Acute Ischemic Stroke [SYNTHESIS], Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy [MR RESCUE], Interventional Management of Stroke III [IMS III]) showed negative outcomes Later criticized for later intervention times, lack of pretreatment vascular imaging to select appropriate patients, and use of older devices instead of newer stent retrievers. Subsequent trials (MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME) have demonstrated positive results Particularly when using imaging selection to identify patients with anterior circulation proximal occlusions, treating mainly with stent retrievers. Accepted time window: 6 hours within symptom onset MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME

HOSPITAL-BASED COMPLICATIONS

Hospital-Based Complications 25% of stroke patients have a medical complication during hospitalization Most common: fever Usually a systemic infection  can lead to worsening neurologic outcomes Use oral antipyretics (acetaminophen, ibuprofen), external cooling, or internal cooling (rarely) Antibiotics if confirmed infection or if high suspicion Common infections: UTI & Pneumonia Avoid foleys or use for < 24 hrs Pts w/ decreased consciousness and/or CN dysfunction are at highest risk for pneumonia Dysphagia screen/swallow study before feeds Consider NG tubes for nutrition & meds

Hospital-Based Complications Hypo/Hyperglycemia Venous thromboembolism SCDs and/or low molecular weight heparin (e.g. lovenox) for DVT prophylaxis within 48 hours of hospitalization Wait at least 24 hours following tPA

POST-Stroke Management

Rehabilitation Assess within first 2 days after a stroke PM&R, PT, OT, and ST PT e.g. ankle foot orthoses and other gait assist devices OT Activities of daily living ST Speech and swallow Post-stroke depression (30% of patients) Discharge to inpatient rehab  improves odds of independence

Stroke eval & Secondary Prevention Etiology: Artery-artery embolism Cardioembolic Small vessel disease (lacunar) Cryptogenic Routine eval: Carotid imaging (ultrasound or CTA), cardiac rhythm monitoring for Afib, fasting glucose/HbA1c, fasting lipid panel, echocardiogram (TTE first then TEE).

Antiplatelet agents Aspirin (81mg or 325mg) Reduces risk of recurrent stroke by 15% HCT 24 hours post-stroke to exclude hemorrhagic transformation before starting If pt was already on aspirin: Switch to clopidogrel (plavix) or dipyridamole-aspirin If large-vessel intracranial stenosis 2/2 atherosclerosis: Combination aspirin and clopidogrel (plavix) for 90 days, followed by aspirin for life New studies suggest combination aspirin/clopidogrel may be beneficial for 90 days in transient ischemic attack (TIA) and minor ischemic strokes Clopidogrel in High-Risk Patients with Acute Non-Disabling Cerebrovascular Events (CHANCE) trial; Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial

Anticoagulation Atrial fibrillation CHADS2-VASc score Start oral anticoagulation within 1-2 weeks Warfarin Novel anticoagulants: dabigatran, apixaban, rivaroxaban

Carotid Stenosis Symptomatic ipsilateral carotid stenosis >70% Surgical revascularization preferably in < 2 weeks from a nondisabling stroke Carotid stenting may be equivalent to carotid endarterectomy Asymptomatic carotid stenosis Medical management

Additional Stroke Education Healthy diet (Mediterranean) Routine exercise (20-30 minutes/day) Smoking cessation Lipid lowering Atorvastatin or Rosuvastatin Goal: LDL <70mg/dL in diabetics LDL <100 mg/dL in all other ischemic stroke patients Secondary stroke prevention provides ~60% risk reduction