Ann M. Hoff, MD ETC Physician Trinity Health

American Stroke Association  Guidelines for the Early Management of Adults with Ischemic Stroke (2007)  “Time is Brain”

Stroke Facts  In the US, someone has a stroke every 40 seconds Every 3-4 minutes, someone dies of stroke  > 700,000 strokes and > 150,000 stroke deaths each year  Stroke is the 3 rd leading cause of death

 Stroke is the leading cause of long-term disability  Ischemic strokes account for 85% of all strokes  In 2009, stroke cost the US $68.9 billion

Stroke Signs/Symptoms  5 most common signs/symptoms Sudden numbness/weakness of the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden dizziness, trouble walking, or loss of balance/coordination Sudden severe headache with unknown cause

Stroke Risk – Race/Ethnicity  African Americans have the double the risk of stroke in comparison to Caucasians  Hispanic Americans fall between Caucasians and African Americans  African and Hispanic Americans are more likely to die following a stroke than are Caucasians

Stroke Risk - Age  Nearly one quarter of strokes occur in people under the age of 65

Stroke Risk Factors  In 2003, approximately 37% of adults reported having two or more of the risk factors listed above.

US Stroke Map

Hospitalizations

Mortality

ND Hospitalizations

ND Mortality

Prehospital Management  EMS Utilization 29-65% 62-95% of EMS activations occurred by an individual other than the patient Dispatcher identified 52% of patients ultimately proven to have had a stroke on the initial telephone conversation

 19-60% present within 3 hrs  14-32% present within 2 hrs  Decreased time to physician exam, CT, and neuro evaluation

EMS Care  Rapid identification of stroke  Identification of possible stroke mimics 19-31%  ABCs  Transport  Notify ER

Community Ambulance

Cincinnati Stroke Scale

 ACT F.A.S.T. Facial Droop Arm Weakness Speech Time

Golden Hour of Stroke

Emergency Room Care  The First 15 Minutes Acute Stroke Protocol ○ Focused H&P ○ NIHSS ○ Labs ○ IVs ○ EKG ○ Weight ○ Alert pharmacy to possible need for tPA ○ Order CT scan

Stroke Alert Team Response ER MD Neuro MD Recorder EKGCT TECHLAB Radiologist

Clinical Assessment  mY33Hhc&feature=player_embedded#! mY33Hhc&feature=player_embedded#

Treatment  Emergency Treatment Based on results of head CT and time of symptom onset

 No blood on CT, < 3hrs from onset Review inclusion/exclusion criteria Obtain consent If tPA given, admit to ICU for 24 hrs

 No blood on CT, > 3hrs & < 8 hrs Off-label IV tPA up to 4.5 hrs Further imaging may expand treatment options: ○ CT angiogram IA tPA Mechanical thrombectomy -MERCI clot retrieval system (8/2004) -Penumbra system (12/2007)

 No blood on CT, > 8 hrs 325 mg of aspirin ○ Reduces early death ○ Reduces long-term disability

 Prevention 1 in 8 stroke survivors will have another stroke within 5 years Treatment of underlying cause is important  Education  Rehabilitation PT/OT to relearn skills

Resources  Management of Ischemic Stroke: Part 1. Emergency Room Management. Journal of Hospital Medicine. Vol 5; No1; January  Guidelines for the Early Management of Adults with Ischemic Stroke. Stroke 2007, 38: ; April 12,  CDC  American Heart Association  American Stroke Association  National Stroke Association  Mayo Clinic  Genentech