1. Acute Care of Ischemic Stroke
Rafid Mustafa, MS-IV
August 9, 2016

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

3. 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…

4. Next Steps?

5. 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

6. Stroke Management: Pre-Hospitalization

7. 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!

8. Stroke Management: EMERGENCY EVALUATION

9. 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

10. 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%.

11. 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

12. Stroke Management: ACUTE THERAPY

13. 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 hrs, but is recommended
European Cooperative Acute Stroke Study III (ECASS III) trial
Consent is important
No benefit beyond 4.5 hrs

14. Acute Therapy: IV tPA

15. 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

16. 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

17. HOSPITAL-BASED COMPLICATIONS

18. 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

19. 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

20. POST-Stroke Management

21. 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

22. 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).

23. 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

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

25. 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

26. 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