Ray Taylor Valencia Community College Department of Emergency Medical Services

Overview Background Anatomy/Physiology Major Stroke Syndromes Assessment and Evaluation Diagnosis Prehospital Case Studies Summary

Questions

Question Hemorrhagic stroke accounts for what percent of all strokes? A. Less than 5% B. 15% - 20% C. 50% D. 80%

Question Which one of the following events causes the majority of ischemic strokes? A. Ventricular fibrillation B. Thromboembolism C. Atrial fibrillation D. Intracerebral hemorrhage

Question In a patient suspected of having an acute brain attack, which one of the following is the best way to differentiate between an ischemic or hemorrhagic cause? A. The history B. The physical examination C. A CT scan of the brain D. An MRI scan of the brain

Question A patient has sudden weakness of the left arm and leg. EMS is called and the patient’s blood pressure is found to be 250/150mmHg. The most appropriate action to be taken by EMS is to monitor and record the blood pressure and: A. Administer labetalol 15mg IV B. Administer nifedipine 10mg SL C. Administer NTG SL D. Do not administer any antihypertensive agent

Question Which one of the following pairings is incorrect? A. Left brain dysfunction – right sided weakness B. Brainstem dysfunction – slurred speech C. Cerebellum dysfunction – dyscoordination D. Subarachnoid hemorrhage – inappropriate speech

Question Which one of the following is true regarding the “ischemic penumbra”? A. It is brain tissue with irreversible ischemia B. It is unaffected by the use of TPA C. It is worsened by hypotension D. Can be seen on a CT scan of the brain

Question All of the following are true statements regarding stroke, except: A. It is the leading cause of disability in the US B. It is a preventable condition C. Death from stroke may be reduced by the treatment with TPA D. Its incidence increases with age

Question All of the following are signs of a brainstem stroke, except: A. Aphasia B. Hemisensory loss C. Nausea and vomiting D. Vertigo

Question All of the following assessments are components of the initial on-site prehospital stroke examination, except: A. Reflexes B. Speech C. Facial symmetry D. Arm strength

Background (USA) #1 Disability #3 Killer 50 million dollars per year 20% mortality 50 million dollars per year Old therapy rehabilitation reduce risk of future strokes Current therapy acute interventions reduce brain area of ischemia Blood sugar Blood pressure

Background Median Hours to ED Arrival (EMS vs Car) 2nd Goal Goal Kothari.(Cincinnati) Ann Emerg Med 1999; 33: 1.

Background Median Time (Hours) Spent Evaluating Stroke Patients (Prehospital = time at home + EMS [small part]) Kothari (Cincinnati). Ann Emerg Med 1999; 33: 1.

Background - Who is Eligible O’Connor RE. Ann Emerg Med 1999; 33: 9-14

Anatomy & Physiology Posterior cerebral Anterior Cerebral Artery leg > arm - opposite side of ischemia sensory deficits = motor deficit sites frontal lobe - impaired judgement/insight Middle Cerebral Artery face/arm > leg: ignore side/site of deficit sensory = motor deficit sites aphasia = speech Posterior cerebral vision/mentation Vertebrobasilar vertigo/gait/cranial nerves (face/eyes/tongue) syncope***

Anatomy & Physiology Ischemic Stroke Hemorrhagic Stroke TIA low flow occluded blood vessel (carotid) embolic - clot travels from heart 80% Hemorrhagic Stroke 20% bleed into brain - stop TIA temporary deficit - < 30-60 minutes high risk of future stroke

Ischemic Stroke Most common cause: thromboembolism CLOT INFARCT Most common cause: thromboembolism Possible sources of clot: Heart Large artery (to brain) Small artery (in brain) Clot occluding artery

Ischemic Stroke: Modifiable Risk Factors Hypertension (systolic and diastolic) Cigarette smoking Prior stroke/ TIA Heart disease Diabetes mellitus, hyperlipidemia Hypercoagulable states Carotid bruit Cocaine, excess alcohol

Ischemic Stroke: Nonmodifiable Risk Factors Advanced age Male gender African-American heritage Family history of early stroke or MI

Intracerebral Hemorrhage Most common cause: chronic hypertension Other causes: Vessel malformation Tumor, bleeding abnormalities Bleeding into brain

Subarachnoid Hemorrhage Most common cause: aneurysm rupture Other causes: Vessel malformation Tumor, bleeding abnormalities Bleeding around brain

Transient Ischemic Attack (TIA) Reversible focal dysfunction, usually lasts mins Among TIA pts who go to ED: 5% have stroke in next 2 days 25% have recurrent event in next 3 months Decrease stroke risk with proper therapy: artery source—antiplatelet (ASA), surgery heart source—anticoagulation (warfarin)

Background Risk of Stroke Following A Transient Ischemic Attack

Time Is Brain: Save The Penumbra Core Clot in Artery

Time is Brain: Save the Penumbra In first few hours of ischemic stroke, brain tissue can still be saved Zone of reversible ischemia (“penumbra”) surrounds core of irreversible infarction Patient symptoms due to both infarcted core and ischemic penumbra One cannot determine by exam how much brain can still be saved

Time is Brain: Save the Penumbra Thrombolytic (fibrinolytic) agent t-PA can limit brain damage safely if given w/in 3 h—it reduces risk of disability due to ischemic stroke by 30% Administer t-PA only if: clinical diagnosis confirmed by CT scan within 3 hours of onset age 18 or older no other contraindications

Major Stroke Syndromes LEFT HEMISPHERE RIGHT HEMISPHERE BRAINSTEM CEREBELLUM HEMORRHAGE 1 1 2 2 5 3 4 4 5 3

Left (Dominant) Hemisphere: Typical Signs (Right Side and Aphasia) Right Visual Field Deficit Aphasia Left Gaze Preference Right Hemiparesis Right Hemisensory Loss

Right (Nondominant) Hemisphere: Typical Signs (Left Side) Left Hemi-inattention Left Visual Field Deficit Right Gaze Preference Left Hemiparesis Left Hemisensory Loss

Brainstem: Typical Signs (Both Sides) Crossed Signs (1 side of face and contralateral body Quadriparesis Sensory Loss in All 4 Limbs Hemiparesis Hemisensory Loss

Brainstem: Typical Signs (continued) Decreased LOC Nausea, Vomiting Hiccups, Abnormal Respirations Vertigo, Tinnitus Eye Movement Abnormalities: Diplopia Dysconjugate Gaze Gaze Palsy Oropharyngeal Weakness: Dysarthria, Dysphagia

Cerebellum: Typical Signs (Coordination) Ipsilateral Limb Ataxia (dyscoordination) Truncal or Gait Ataxia (imbalance)

Symptoms Suggestive of Hemorrhage Both Subarachnoid and Intracerebral Hemorrhage: Headache Nausea, Vomiting Decreased LOC Subarachnoid Hemorrhage: Intolerance to Light Neck Stiffness / Pain Intracerebral Hemorrhage: Focal Signs Such as Hemiparesis

The Focused Neurologic Assessment and Evaluation

Cincinnati and LA Prehospital Stroke Scales Perform on scene during Primary Survey under “D” – Disability: Speech Facial Droop Arm Drift Grip “Speech, Droop, Drift, Grip!”

(Aphasia = left hemisphere Dysarthria = cranial nerves) Speech: Repeat Phrase “You can’t teach an old dog new tricks.” Abnormal: Wrong or inappropriate words (aphasia) Slurred words (dysarthria) or unable to speak (Aphasia = left hemisphere Dysarthria = cranial nerves)

Facial Droop (Cranial Nerves): Show Teeth or Smile Abnormal: One side of face does not move as well as the other side Right-sided droop © AHA 1997

Arm Drift (Motor): Close Eyes, Hold Out Arms Abnormal: One arm does not move or drifts down Right-sided drift © AHA 1997

Prehospital Stroke Scale Grip Normal right and left Abnormal right or absent right Abnormal left or absent left Comparison of sides

Prehospital Stroke Identification Smith. Prehospital Emerg Care 1998; 2: 170. Kidwell (Los Angelos) Stroke 2000; 31: 71. Kothari (Cincinnati). Ann Emerg Med 1999; 33: 373.

Cincinnati Prehospital Stroke Scale Normal Patient Click picture to play video

Miami Emergency Neurologic Deficit Exam Expanded Prehospital Stroke Exam MENTAL STATUS CHECK IF ABNORMAL Level of Consciousness (AVPU) Speech “You can’t teach an old dog new tricks.” (repeat) Abnormal = wrong words, slurred speech, no speech Questions (age, month) Commands (close, open eyes) CRANIAL NERVES Facial Droop (show teeth or smile) RT LT Abnormal - one side does not move as well as other Visual Fields (four quadrants) Horizontal Gaze (side to side) LIMBS Motor–Arm Drift (close eyes and hold out both arms) RT LT Abnormal–arm can’t move or drifts down Leg Drift (open eyes and lift each leg separately) Sensory–Arm and Leg (close eyes and touch, pinch) Coordination–Arm and Leg (finger to nose, heel to shin)

Miami Emergency Neurologic Deficit Exam Normal Patient Click picture to play video

Cincinnati Prehospital Stroke Scale Left Hemispheric Stroke Click picture to play video

Miami Emergency Neurologic Deficit Exam Left Hemispheric Stroke Click picture to play video

Diagnosis and Management Prehospital Exclude masqueraders hypoglycemia/hyperglycemia drugs/toxins trauma hypoxia Neurologic screen Cincinnati/LA prehospital stroke scale not meant to be 100% accurate

Management - Glucose Neurologic Effects of Lo glucose vs. Very Hi glucose on Infarcted Brain (Rabbit Model) Thoralf. Stroke 1999; 30: 160-170.

Management - Glucose Pulsinelli. Am J Med 1983; 74: 540.

Management - Blood Pressure Relationship of CNS tissue perfusion (SPECT scan) to drop in BP after treatment Lisk. Arch Neurol 1993; 50: 855.

Acute Stroke Patients: Indications for Antihypertensive Therapy In general: Consider: absolute level of BP? If BP: >185/>110 mm Hg = fibrinolytic therapy contraindicated Consider: other than BP, is patient candidate for fibrinolytics? If patient is candidate for fibrinolytics: treat initial BP >185/>110 mm Hg Consider: response to initial efforts to lower BP in ED? If treatment brings BP down to <185/110 mm Hg: give fibrinolytics Consider: ischemic vs hemorrhagic stroke? Treat BP in the 180-230/110-140 mm Hg range the same The obvious: no fibrinolytics for hemorrhagic stroke

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 >230/121-140 mm Hg 180-230/105-120 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 Review suggested antihypertensive therapy for patients with suspected ischemic stroke. Note: Course participants with a first printing of the 1997 ACLS Textbook should correct it to reflect the most recent versions of Tables 7 and 8 as published in the 1997 ECC Handbook. MAP is estimated by one third the sum of systolic and double diastolic pressure. Labetalol should be avoided in patients with asthma, cardiac failure, or severe abnormalities in cardiac conduction. For refractory hypertension, alternative therapy may be considered with sodium nitroprusside, enalapril, or nicardipine.

Diagnosis and Management ED Diagnosis History and Physical in ED Supplemented with CT normal in 1st 24-48 hours Thrombolytic Therapy

Emergent CT Scan Is necessary to rule out nonstroke cause of symptoms Is necessary to differentiate ischemic vs. hemorrhagic stroke Exam alone cannot distinguish stroke vs. nonstroke or ischemia vs. hemorrhage

Noncontrast CT Scan: Ischemic Stroke (Left Hemisphere) R 4 Hours L R 4 Days L Subtle blurring and compression of sulci Obvious dark changes of infarction

Noncontrast CT Scan: Hemorrhagic Strokes Intracerebral Hemorrhage Subarachnoid Hemorrhage R L R L “Ball” of white blood in thalamus White blood in cisterns & 4th ventricle

What Pathology Does This Scan Show? Scan A Scan A has a well-defined hypodensity in the left hemisphere consistent with a significant acute ischemic event (3 hours in duration). As a result, this patient would not be a candidate for fibrinolytics. Note that if the hypodensity is thought to be 3 months old, it does not constitute a contraindication to fibrinolytics. There are hyperdense (white) areas that represent calcification in the choroid plexus rather than bleeding.

What Pathology Does This Scan Show? Scan A Hypodense area: Ischemic area with edema, swelling Indicates >3 hours old No fibrinolytics! Scan A has a well-defined hypodensity in the left hemisphere consistent with a significant acute ischemic event (3 hours in duration). As a result, this patient would not be a candidate for fibrinolytics. Note that if the hypodensity is thought to be 3 months old, it does not constitute a contraindication to fibrinolytics. There are hyperdense (white) areas that represent calcification in the choroid plexus rather than bleeding. Right Left

What Pathology Does This Scan Show? Scan B Scan B shows a large left frontal intracerebral hemorrhage. Intraventricular hemorrhage is present. This patient is not a candidate for fibrinolytics.

What Pathology Does This Scan Show? Scan B (White areas indicate hyperdensity = blood) Large left frontal intracerebral hemorrhage. Intraventricular bleeding is also present No fibrinolytics! Scan B shows a large left frontal intracerebral hemorrhage. Intrav- entricular hemorrhage is present. This patient is not a candidate for fibrinolytics. Right Left

What Pathology Does This Scan Show? Scan C Scan C shows diffuse areas of white (hyperdense) images consistent with an acute subarachnoid hemorrhage. The hemorrhage is visible in several areas on the surface of the brain. A patient like this is not a candidate for fibrinolytic therapy. CT findings may be more subtle than these.

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 Scan C shows diffuse areas of white (hyperdense) images consistent with an acute subarachnoid hemorrhage. The hemorrhage is visible in several areas on the surface of the brain. A patient such as this is not a candidate for fibrinolytic therapy. CT findings may be more subtle than these.

Management - Thrombolytics Percent of Patients with Minimal/No deficit at 3 months NINDS. New Engl J Med 1995; 333: 1581.

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 Review inclusion criteria: all must be present for fibrinolytic therapy to be initiated.

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 <100 000 mm3 — Patients who received heparin in last 48 hours; have elevated PTT — Recent anticoagulant use (eg, coumadin); have elevated PT Review exclusion criteria: all must be absent for fibrinolytic therapy to be initiated. Note: The instructor has the option of indicating the presence of one exclusion criterion to determine if participants will later correctly exclude the patient from fibrinolytic therapy if the ischemic stroke branch is used.

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 Review exclusion criteria: all must be absent for fibrinolytic therapy to be initiated.

Management - thrombolytics Requirements - all within 3 hours Recognition/identification potentially eligible patients History Awaken with weakness does NOT count) Exclusion criteria Exam detailed NIH stroke scale CT scan must be read by neuro-radiologist (subtle exclusions) Consent

Management - other options New neuroprotective agents Selective intra-arterial thrombolytics angioplasty? Stents/coils? EXTENDS window to 4-6 hours

Acute Stroke Algorithm Suspected Stroke 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 Detection Dispatch Delivery Door 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) Have students follow the algorithm in their textbook or in the 2000 ECC Handbook.

Case-Based Prehospital Scenarios

Click picture to play video Case 1: On scene Click picture to play video

Case 1:Transport (patient is 60 / month is December) Click picture to play video

Case 1: Discussion 1. Is this more likely a stroke or stroke mimic? 2. What are the physical findings? 3. Where in the brain is the abnormality? 4. Is the radio report complete? 5. Is this patient a candidate for t-PA? 1. What stroke syndrome do you suspect? - Left hemisphere 2. What are the physical findings? - Expressive aphasia - Right facial droop - Right visual field cut - Left gaze preference. Right gaze deficit. - Right arm drift - Right leg drift - Right hemi-sensory loss - Normal coordination, but limited on right by weakness 3. Is the radio report complete? - 4. Is this patient a candidate for thrombolytics? - Yes

Click picture to play video Case 2: On Scene Click picture to play video

Case 2:Transport (patient is 45 / month is December) Click picture to play video

Click picture to play video Case 2: Radio Report Click picture to play video

Case 2: Discussion 1. Is this more likely a stroke or stroke mimic? 2. What are the physical findings? 3. Where in the brain is the abnormality? 4. Is the radio report complete? 5. Is this patient a candidate for t-PA?

Click picture to play video Case 3: On Scene Click picture to play video

Case 3:Transport (patient is 48 / month is October) Click picture to play video

Click picture to play video Case 3: Radio Report Click picture to play video

Case 3: Discussion 1. Is this more likely a stroke or stroke mimic? 2. What are the physical findings? 3. Where in the brain is the abnormality? 4. Is the radio report complete? 5. Is this patient a candidate for t-PA?

Click picture to play video Case 4: On Scene Click picture to play video

Case 4:Transport (patient is 69 / month is December) Click picture to play video

Click picture to play video Case 4: Radio Report Click picture to play video

Case 4: Discussion 1. Is this more likely a stroke or stroke mimic? 2. What are the physical findings? 3. Where in the brain is the abnormality? 4. Is the radio report complete? 5. Is this patient a candidate for t-PA?

Maximum Intervals Recommended by NINDS Summary Key Evaluation Targets for Stroke Patient: Potential Fibrinolytic Candidate? Maximum Intervals Recommended by NINDS Door-to–doctor first sees patient …….………… 10 min Door-to–CT completed …….………………….. 25 min Door-to–CT read ...…………..………………… 45 min Door-to–fibrinolytic therapy starts …………….. 60 min Neurologic expertise available* …..…………… 15 min Neurosurgical expertise available* …………… 2 hours Admitted to monitored bed ..……...…………… 3 hours Review times. Answer 1: Review the patient’s history, verify time of symptom onset, and perform brief physical and neurologic examinations. Answer 2: The NIHSS measures neurologic function, which correlates with ischemic stroke severity and long-term outcome. It can be performed in 7 minutes and can be performed simultaneously with initial admission procedures, so it should not delay other assessment or therapy. It enables performance of serial standardized neurologic evaluation over time by a nurse or physician. This stroke scale is shown in the ACLS Textbook and the 2000 ECC Handbook. The NIHSS is not a comprehensive neurologic exam, and further studies may be required. The NIHSS evaluates the following 5 areas, and the resulting score (0-42) will guide decisions about therapy: Level of consciousness Visual assessment Motor function Sensation and neglect Cerebellar function Training in the NIHSS is beyond the scope of this course but will be included in the advanced ACLS course. Videotapes are available to teach the use of this scale. Additional scales: Hunt and Hess Scale for subarachnoid hemorrhage and Glasgow Coma Scale. See the ACLS Textbook.

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