Acute Stroke: Recognizing and Reacting Dr. Grant Stotts Stroke Neurologist, Ottawa Hospital

Stroke and MI Share many common causes –Blood pressure, smoking, cholesterol... Both result in blood clots stopping circulation –Therefore, acute treatment may involve similar approaches

Presentation Goals Review the signs of stroke Emphasis the crucial role fast response plays in stroke treatment Recognize potential of available treatments –Acute –Preventative

Warning Signs of Stroke 1.Weakness 2.Troubles Speaking 3.Vision Problems 4.Sudden Headache 5.Dizziness

Updated October 2006 Warning Signs of Stroke Weakness –Sudden loss of strength or sudden numbness in the face, arm or leg, even if temporary

Updated October, 2006 Warning Signs of Stroke Trouble Speaking –Sudden difficulty speaking or understanding or sudden confusion, even if temporary.

Updated October, 2006 Warning Signs of Stroke Vision Problems –Sudden trouble with vision, even if temporary.

Updated October, 2006 Warning Signs of Stroke Headache –Sudden severe and unusual headache.

Updated October, 2006 Warning Signs of Stroke Dizziness –Sudden loss of balance, especially with any of the above signs.

Stroke Warning Signs Stroke recognition is impaired by: –Lack of awareness –Lack of pain Weakness Troubles Speaking Vision Problems Headache Dizziness

A Stroke in Ottawa

Identify possible stroke Alert EMS Immediate transport Immediate triage (stroke code) –Initiates calls to CT room, neurologists –Necessary blood work is done –Patient taken to CT (computerized tomography) scanner

Normal CT

CT With a Stroke

CT With a Bleed

Acute Stroke Treatment tPA If no bleed and < 3 hours, considered for acute treatment Standard is presently tPA - intravenous –Improves relative chance of survival or reduced disability by about 30% –Risk is bleeding (about 6% of those who receive it)

Time is Everything Time is the most important factor –Nothing else is more important to open up the artery

Intra-arterial tPA Intraveneous tPA is limited to being given within 3 hours SELECT patients from 3 to 6 hours may qualify for intra-arterial therapy –Guiding a catheter through the arteries up to the clot and giving a small dose of tPA –Similar to heart attacks, angioplasty and stenting can now be done in certain vessels

MR Angiogram

Blocked middle cerebral arteryRestored flow

MERCI DEVICE More recent option is to remove the clot (mechanical extraction) –MERCI Device –Currently available in Ottawa Used in SELECT cases where tPA is felt unlikely to work Made popular by ER

APM0097_A_1991 Merci Retriever

APM0097_A_1991 Merci System Animation

Courtesy: Dr. M. Sharma Telestroke Technology Efilm Server Base Hospital Remote Hospital ISDN or VPN VPN

Research Presently Taking Place

Desmoteplase New agent for breaking up blood clots Given IV Similar to tPA

sICH Low = Stringent Dependence on Fibrin Therapeutic window 9hr Low Fibrinogenlysis t 1/2 = 138 min Desmoteplase Desmodus rotundus Vampire Bat Salivary PA Recombinant DSPAα1 High Fibrin Selectivity

CT Perfusion Imaging in Acute Stroke – Ischemic Penumbra CBV (ml/100g) CBF (ml/100g/min) MTT (sec) CBV CBF MTT

How Well Are We Doing Now?

Courtesy: Dr. Michael Sharma, Medical Director Stroke Program, The Ottawa Hospital Ontario tPA Rates by Hospital 2003 Overall tPA Rate 9% (Ischemic Patients) N = 4,107

Improvements Presented here by Dr. Sharma 2003 –Increase awareness of stroke signs Heart and Stroke Ad Campaigns –EMS directed to hospitals with stroke teams –Stroke code protocols in ER –Neurologists on call

Courtesy: Dr. M. Sharma

Canadian and Ontario Stroke Strategies

Best Practice across the Continuum of Care The Ontario Stroke System Stroke Strategy Principles: Comprehensive Integrated Evidence-based Province Wide Stroke recognition Prevention Prehospital Emergency Acute Rehab Community Transition

Stroke in Canada The leading cause of adult disability 4th leading cause of death One stroke every ten minutes in Canada 50,000 strokes per year 20,000 new strokes in Ontario per year 300,000 stroke survivors 28% of stroke patients are under age 65 Statistics Canada Kiely DK, et al. Stroke 1993;24:

Cost of Stroke The cost of the disease is more than $3 billion a year in Canada Stroke has longest LOS of any disease The rate of hospitalization for stroke is over 20 times higher for those 65 and over Average acute care cost estimated at $27,500

Outcome of Ischemic Stroke Adapted from Stegmayr B, et al. Stroke 1997;28:

11 Regions 9 Regional Stroke Centres 2 Enhanced District Stroke Centres 16 District Stroke Centres 24 Stroke Prevention Clinics

Champlain Region

Impact of an integrated strategy: The Ontario Stroke Strategy  54% increase in patients receiving referrals to stroke prevention clinics following initial stroke/TIA to prevent more serious event (there are now 24 prevention clinics in Ontario)  tPA: A clot-busting drug - the only proven treatment in stroke: –Average tPA rate increased from 25% to 34% in designated regional stroke centres  Inpatient admissions for stroke decreased by 11%, mostly attributable to a decrease in admissions for transient ischemic attacks (TIA) or small strokes 2005 Evaluation of the Ontario Stroke Strategy - comparisons made between 2000 (before the Ontario Stroke Strategy was implemented) and 2003 (after the strategy was implemented)

Impact of an Integrated Strategy  Number of patients now managed on specialized stroke units increased from 18% to 60%  Decreased utilization in inpatient resources  Physiotherapy assessments before hospital discharge have increased from 47% to 75%, and occupational therapy consults from 38% to 71%  85% of patients discharged on antiplatelet medications to help prevent another stroke  8.7% of patients require admission to long-term care - major decrease from two years previously

Economic impact of an integrated stroke strategy  Based on current Canadian population, the net benefit of providing coordinated stroke care, over next 20 years: –Prevent 160,000 strokes –Prevent disability in 60,000 Canadians –Achieve net savings of $8 billion  Economic analysis is very conservative - does not include: –primary prevention interventions other than hypertension, –secondary prevention clinics, and –improved post-acute rehabilitation  Projected impact would be significantly higher  Source: Dr. Mike Sharma (in partnership with Caro Research) - based on systems changes implemented through the Ontario Stroke Strategy, extrapolated for all of Canada, multiple data sources

Awareness of Stroke Warning Signs Aware of 2 or more signs Aware of key warning signs Dizziness Vision problems Trouble speaking Headache 2003(%)2005(%)

Ottawa Performance 2006 Stroke patients arriving in ER within 2.5 hours –42.5% If patient arrives within 2.5 hours, chance of getting tPA –47% Stroke patients arriving by ambulance –57.5%

What If The Symptoms Are Temporary?

TIA Management TIA is the equivalent of angina –Warning sign of stroke

Gladstone et al, CMAJ, 2004, Mar 30:170(7):1099 Risk of Stroke After TIA

Ottawa Stroke Prevention Clinic All TIA patients triaged for rapid referral –Carotid doppler and echocardiogram –Placed on antiplatelet therapy –Options for statins and BP agents provided

Summary Effective treatments exist for stroke The key to acute treatment is TIME –Recognition of stroke symptoms –Activation of EMS –Rapid triage of minor and serious strokes/TIAs

Warning Signs of Stroke 1.Weakness 2.Troubles Speaking 3.Vision Problems 4.Sudden Headache 5.Dizziness