1. Stroke Systems and Stroke Scales in the Management of Acute Stroke Patients Kama Guluma, MD

2. Kama Guluma, MD Assistant Professor Department of Emergency Medicine University of California San Diego Medical Center San Diego, CA

3. Objectives Understand the concept of Stroke Systems and Stroke Centers, and the benefits these provide to ED physicians and the patients we care for Understand the concept of EMS triage of stroke patients Understand what the NIHSS stroke scale means for the clinical exam and clinical decision making Understand what the mRS, GOS and BI mean for a interpretation of stroke outcome Kama Guluma, MD

4. The Stroke Chain-of-Survival Patient Awareness 911 CallEDEMS Stroke Team Response Stroke Unit Kama Guluma, MD

5. The Problem Blind Men and the Elephant, by Antonello Silverini Kama Guluma, MD

6. The Problem Blind Men and the Elephant, by Antonello Silverini Fragmentation of health care delivery results in suboptimal treatment, errors, and safety concerns There may be a lack of expertise or resources at one or another site Exacerbated in rural or underserved areas Kama Guluma, MD

7. The Brain Attack Coalition a multidisplinary group American Academy of Neurology American Association of Neurological Surgeons American Association of Neurosciences Nurses American College of Emergency Physicians American Heart Association American Society of Neuroradiology National Institute of Neurologic Disorders and Stroke National Stroke Association Stroke Belt Consortium Kama Guluma, MD

8. The Trauma System Kama Guluma, MD

9. 2000: Brain Attack Coalition Primary Stroke Centers Kama Guluma, MD JAMA 2000; 283:3102-3109

10. PRIMARY STROKE CENTERS Key recommendations by the BAC Patient Care Areas –Emergency medical services –Emergency Department –Acute stroke teams –Written protocols –Stroke unit –Neurosurgical services Support Services –Commitment & support of medical organization; stroke center director –Neuroimaging services –Laboratory services –Outcome & quality improvement activities –Continuing medical education Kama Guluma, MD

11. PRIMARY STROKE CENTERS Key recommendations by the BAC EMS: –High-priority stroke transports –Written agreements and transport protocols –Fluid administrative line of communication between Stroke Center and EMS –Cooperative educational activities at least semi-annually Kama Guluma, MD

12. PRIMARY STROKE CENTERS Key recommendations by the BAC Emergency Department: –ED personnel trained in stroke care –Established lines of communication with EMS to prepare for stroke patient arrival –ED representation on Stroke Team –Triage protocol –Treatment protocol (e.g., diagnostics, meds, imaging, BP mgm’t) –Stroke treatment education semiannually Kama Guluma, MD

13. PRIMARY STROKE CENTERS Key recommendations by the BAC Acute stroke team: –A physician with cardiovascular expertise + another person (nurse, PA, NP) –Available 24/7 to respond to acute stroke –Specific and organized paging mechanism –15-minute response time –Log and CQI process Kama Guluma, MD

14. PRIMARY STROKE CENTERS Key recommendations by the BAC Stroke Unit –nurses and physicians with stroke training –BP monitoring –can be part of an ICU (e.g. dedicated beds) Neurosurgical service –24/7 access (in house or via transfer) within 2 hrs –call schedule, written transfer agreements Neuroimaging –24-hour availability –brain CT or MRI within 25 minutes –radiologist or neurologist read within 20 minutes (in house or via teleradiography) Laboratories with 45 minutes Kama Guluma, MD

15. PRIMARY STROKE CENTERS Expected benefits Improved efficiency of patient care Increased use of acute stroke therapies Fewer complications Reduced mortality and morbidity Improved long term outcomes Reduced costs to healthcare system Increased patient satisfaction Kama Guluma, MD

16. PRIMARY STROKE CENTERS Implications/benefits for the Emergency Physician Acute care supported by a Stroke Team (of which EM would/should be an integral part) and the institution Streamlined protocols for patient disposition (ICU, transfer, admission) Institutionalized neurology, neuroradiology and neurosurgical backup Collateral improvements (ICH, SDH, SAH, imaging, labs) Education/CME Kama Guluma, MD

17. JCAHO Certification Joint Commission on Accreditation of Health Care Organizations Kama Guluma, MD

19. 2005: Brain Attack Coalition Comprehensive Stroke Centers Stroke. 2005;36:1597-1618. Kama Guluma, MD

20. COMPREHENSIVE STROKE CENTER Specialized tertiary care referral center (None “certified” yet) In house, 24/7, specialty teams: e.g., interventional neuroradiology, neurosurgery, neurology Might get the “after 3 hour” crowd, large strokes, complex cases, after stabilization at PSCs A place to refer post t-PA patients if needed Research protocols Telemedicine? Kama Guluma, MD

21. Beyond Individual Stroke Centers STROKE SYSTEMS Stroke. 2005;36:690-703 Kama Guluma, MD

22. Beyond Individual Stroke Centers City-wide systems of stroke care Birmingham, AL (with direct EMS Triage) Cincinnati, OH Dallas, TX Houston, TX New York, NY (with direct EMS Triage) Ann Arbor, MI Kama Guluma, MD

23. Beyond Individual Stroke Centers State-wide systems of stroke care From Lily Chaput, MD, California Dept of Health Services Kama Guluma, MD

24. EMS Triage of Stroke Kama Guluma, MD

25. Cincinnati Prehospital Stroke Scale One positive = possible stroke From the National Institute of Neurological Disorders and Stroke Kama Guluma, MD

26. LA Prehospital Stroke Scale “Stroke Code” from the field From the National Institute of Neurological Disorders and Stroke Kama Guluma, MD

27. Dallas Area Stroke Council Stroke Evaluation Sheet Stroke alert from the field From the National Institute of Neurological Disorders and Stroke Kama Guluma, MD

28. Birmingham Regional Emergency Medical Services System Used to enter patients into Stroke System From the National Institute of Neurological Disorders and Stroke Kama Guluma, MD

29. Paramedic accuracy at diagnosing stroke Kama Guluma, MD

30. Stroke Scales Kama Guluma, MD

31. The utility of clinical scales Allow gross quantification of injury/pathology Aid in communication to consultants Can be used to track improvement or deterioration in the acute treatment phase Can be used to track outcome Can be useful research tools Kama Guluma, MD

32. The NIH Stroke Scale Kama Guluma, MD

33. The Stroke-focused Neuro Exam The NIHSS 1.Level of consciousness 2.Gaze 3.Visual fields 4.Facial strength 5.Arm strength 6.Leg strength 7.Limb ataxia (FNF, heel-down-shin) 8.Sensation (pinch/pinprick) 9.Language (re: aphasia) 10.Dysarthria 11.Extinction/inattention (bilat sensory) Maximum Score = 42 Maximum score from ischemic stroke = 31 Kama Guluma, MD

34. The NIH Stroke Scale LEVEL OF CONSCIOUSNESS Kama Guluma, MD

35. The NIH Stroke Scale GAZE VISUAL FIELDS Kama Guluma, MD

36. The NIH Stroke Scale FACIAL MOTOR Kama Guluma, MD

37. The NIH Stroke Scale MOTOR OF THE ARM MOTOR OF THE LEG ATAXIA Kama Guluma, MD

38. The NIH Stroke Scale SENSORY Kama Guluma, MD

39. The NIH Stroke Scale LANGUAGE Kama Guluma, MD

40. The NIH Stroke Scale DYSARTHRIA Kama Guluma, MD

41. The NIH Stroke Scale EXTINCTION/NEGLECT Kama Guluma, MD

42. What the NIHSS score means to the EP NIHSS 1 - 4: mild stroke NIHSS 5 -15: moderate stroke NIHSS 15 – 20: moderate to severe stroke NIHSS > 20: severe stroke Prognosis: likelihood of favorable outcome –NIHSS < 10: 60 – 70% –NIHSS > 20: 4 -16% Stroke. 2003;34:1056 –1083. Kama Guluma, MD

43. What the NIHSS score means to the EP Adams HP, Neurology 1999; 53:126-131 NIHSS vs Outcome at 3 months Kama Guluma, MD

44. What the NIHSS score means to the EP Chance of ICH with tPA –NIHSS < 10: 3% –NIHSS > 20: 17% Max benefit:risk ratio: NIHSS 10 – 20? Stroke. 2003;34:1056 –1083. Ann Emerg Med. 2001;37:202-216 Kama Guluma, MD

45. A limitation of certain scales … The call from the Trauma Bay to a Neurosurgeon “He’s got a GCS of 10” “GCS of 10…what’s the patient’s exam?” Kama Guluma, MD

46. Consideration: the “low NIHSS score” stroke with a devastating effect on livelihood Kama Guluma, MD

47. The lytic treatment decision TREATMENT DECISION NIHSS Clinical data Age Co-morbidities Pre-stroke function Discussion with patient and family Kama Guluma, MD

48. Consideration: The “high NIHSS score” stroke dilemma: 1) “A terminal intracranial bleed” VS 2) “Bedridden for rest of life in a nursing home” Kama Guluma, MD

49. The Stroke-focused Neuro Exam Based on the NIHSS 1.Level of consciousness 2.Visual fields 3.Gaze 4.Facial strength 5.Arm strength 6.Leg strength 7.Limb ataxia (FNF, heel-down-shin) 8.Dysarthria 9.Sensation (pinch/pinprick) 10.Extinction/inattention (bilat sensory) 11.Language (re: aphasia) LOC Vision Motor strength Coordination Sensation Language Kama Guluma, MD

50. Estimating an NIHSS score Do full neuro exam, but focus on four areas of deficit: 1.Unilateral motor deficit 2.Speech and language deficit 3.CN, neglect and visual field deficit 4.Depressed level of consciousness MOTORSPEECH / LANGUAGECN / VISUALLOC 2 / 4 / 8 TOTALEstimated NIHSS Grade as: Mild = 2 Moderate = 4 Severe = 8 From the Foundation for Education and Research in Neurological Emergencies Kama Guluma, MD

52. Functional scales Modified Rankin scale (mRS) Barthel Index (BI) Glasgow Outcome Scale (GOS) Utilize scored assessments of patient’s functional status Can be used to gauge: –pre-morbid baseline –outcome Kama Guluma, MD

53. ScoreDescription 6Dead 5Severe disability: bedridden, incontinent, and requiring constant nursing care and attention 4Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance 3Moderate disability: requiring some help, but able to walk without assistance 2Slight disability: unable to carry out all previous activities, but able to look after own affairs without assistance 1No significant disability: despite symptoms, able to carry out all usual duties and activities 0No symptoms at all Modified Rankin Scale Good outcome = score of 0 - 1 Kama Guluma, MD

54. Modified Rankin Scale Structured interview questions 5 = severe disability: someone needs to be available at all times; care may be provided by either a trained or untrained caregiver. Question: Does the person require constant care? 4 = moderately severe disability: need for assistance with some basic ADLs, but not requiring constant care. Question: Is assistance essential for eating, using the toilet, daily hygiene, or walking? 3 = moderate disability: need for assistance with some instrumental ADL but not basic ADLs. Question: Is assistance essential for preparing a simple meal, doing household chores, looking after money, shopping, or traveling locally? 2 = slight disability: limitations in participation in usual social roles, but independent for ADLs. Questions: Has there been a change in the person’s ability to work or look after others if these were roles before stroke? Has there been a change in the person’s ability to participate in previous social and leisure activities? Has the person had problems with relationships or become isolated? 1 = no significant disability: symptoms present but not other limitations. Question: Does the person have difficulty reading or writing, difficulty speaking or finding the right word, problems with balance or coordination, visual problems, numbness (face, arms, legs, hands, feet), loss of movement (face, arms, legs, hands, feet), difficulty with swallowing, or other symptom resulting from stroke? 0 = no symptoms at all; no limitations and no symptoms Courtesy of Foundation for Education and Research in Neurological Emergencies Kama Guluma, MD

55. Barthel Index Feeding 0 = unable 5 = needs help cutting, spreading butter, etc, or requires modified diet 10 = independent Bathing 0 = dependent 5 = independent (or in shower) Grooming 0 = needs help with personal care 5 = independent face/hair/teeth/shaving (implements provided) Dressing 0 = dependent 5 = needs help but can do about half unaided 10 = independent (including buttons, zips, laces, etc) Bowels 0 = incontinent (or needs enemas) 5 = occasional accident 10 = continent Kama Guluma, MD

56. Barthel Index Bladder 0 = incontinent, or catheterized and unable to manage alone 5 = occasional accident 10 = continent Toilet use 0 = dependent 5 = needs some help but can do something alone 10 = independent (on and off, dressing, wiping) Transfers (bed to chair and back) 0 = unable, no sitting balance 5 = major help (1 or 2 people, physical), can sit 10 = minor help (verbal or physical) 15 = independent Mobility (on level surfaces) 0 = immobile or <50 yards 5 = wheelchair-independent, including corners, >50 yards 10 = walks with help of 1 person (verbal or physical) >50 yards 15 = independent (but may use any aid—eg, stick) >50 yards Stairs 0 = unable 5 = needs help (verbal, physical, carrying aid) 10 = independent 100 point scale; good outcome = 95 - 100 Kama Guluma, MD

57. ScoreDescription 1DEAD 2VEGETATIVE STATE Unable to interact with environment; unresponsive 3SEVERE DISABILITY Able to follow commands/ unable to live independently 4MODERATE DISABILITY Able to live independently; unable to return to work or school 5GOOD RECOVERY Able to return to work or school Glasgow Outcome Scale Kama Guluma, MD

58. Functional scales and tPA outcome NINDS tPA trial: –13% absolute increase in mRS 0 – 1 in treatment group –12% increase in BI 95-100 in treatment group –Means: 9 patients need to be treated for one improvement in outcome (NNT = 9) Kama Guluma, MD

59. 1-Year outcome in NINDS trial Barthel Index Modified Rankin Scale Glasgow Outcome Scale Kwiatkowski TG, et al. N Engl J Med. 1999;340:1781-1787. Kama Guluma, MD

60. ScoreDescription 6Dead 5Severe disability: bedridden, incontinent, and requiring constant nursing care and attention 4Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance 3Moderate disability: requiring some help, but able to walk without assistance 2Slight disability: unable to carry out all previous activities, but able to look after own affairs without assistance 1No significant disability: despite symptoms, able to carry out all usual duties and activities 0No symptoms at all Modified Rankin Scale Good outcome = score of 0 - 1 Kama Guluma, MD

61. Looking at NINDS data more closely The sliding scale dichotomy endpoint Saver J, 31 st International Stroke Conference, Kissimmee, FL, Feb 2006 mRS: 0 1 2 3 4 5 6 Baseline-adjusted severity endpoint reanalysis, 3-month outcome NIHSS 0-7 “GOOD” NIHSS 8-14 “GOOD” NIHSS >14 mRS: 0 1 2 3 4 5 6 All NIHSS “GOOD” NNT = 9 NNT = 3 Kama Guluma, MD

62. Summary Changes are coming your way; get and stay involved. –City, county, or state stroke systems –EMS triage –Primary and comprehensive stroke centers –ED-centered acute stroke teams The NIHSS helps quantify and stratify acute stroke –Key aspects of the stroke-focused (NIH scale) neuro exam: LOC, vision, motor, coordination, sensation, language Understanding the mRS, BI, and GOS can aid interpretation of outcome in stroke clinical trials. Kama Guluma, MD