Stroke Systems and Stroke Scales in the Management of Acute Stroke Patients

Stroke Systems and Stroke Scales in the Management of

Acute Stroke Patients

Kama Guluma, MD

Kama Guluma, MD

Assistant Professor

Department of Emergency Medicine

University of California San Diego Medical CenterSan Diego, CA

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

The Stroke Chain-of-Survival

PatientAwareness 911 Call EDEMS

StrokeTeam

Response

StrokeUnit

Kama Guluma, MD

The Problem

Blind Men and the Elephant, by Antonello SilveriniKama Guluma, MD

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

The Brain Attack Coalitiona 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

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The Trauma System

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2000: Brain Attack Coalition Primary Stroke Centers

Kama Guluma, MD JAMA 2000; 283:3102-3109

PRIMARY STROKE CENTERSKey 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


• 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


• 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


• 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


• 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

PRIMARY STROKE CENTERSExpected 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

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

JCAHO Certification

Joint Commission on Accreditation of Health Care OrganizationsKama Guluma, MD

Kama Guluma, MD

2005: Brain Attack Coalition Comprehensive Stroke Centers

Stroke. 2005;36:1597-1618.Kama Guluma, MD

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

Beyond Individual Stroke CentersSTROKE SYSTEMS

Stroke. 2005;36:690-703Kama Guluma, MD

Beyond Individual Stroke CentersCity-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

Beyond Individual Stroke CentersState-wide systems of stroke care

From Lily Chaput, MD, California Dept of Health Services

Kama Guluma, MD

EMS Triage of Stroke

Kama Guluma, MD

Cincinnati Prehospital Stroke Scale

One positive = possible stroke

From the National Institute of Neurological Disorders and StrokeKama Guluma, MD

LA Prehospital Stroke Scale

“Stroke Code” from the field


Dallas Area Stroke Council Stroke Evaluation Sheet

Stroke alert from the field


Birmingham Regional Emergency Medical Services System

Used to enter patients into Stroke SystemFrom the National Institute of Neurological Disorders and Stroke

Kama Guluma, MD

Paramedic accuracy at diagnosing stroke

Kama Guluma, MD

Stroke Scales

Kama Guluma, MD

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

The NIH Stroke Scale

Kama Guluma, MD

The Stroke-focused Neuro ExamThe NIHSS

1. Level of consciousness2. Gaze 3. Visual fields4. Facial strength5. Arm strength6. Leg strength7. Limb ataxia (FNF, heel-down-shin)8. Sensation (pinch/pinprick)9. Language (re: aphasia)10. Dysarthria11. Extinction/inattention (bilat sensory)

Maximum Score = 42

Maximum score from ischemic stroke = 31

Kama Guluma, MD


LEVEL OF CONSCIOUSNESS

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GAZEVISUAL FIELDS

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FACIAL MOTOR

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The NIH Stroke ScaleMOTOR OF THE ARM MOTOR OF THE LEG

ATAXIA

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SENSORY

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The NIH Stroke ScaleLANGUAGE

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The NIH Stroke ScaleDYSARTHRIA

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EXTINCTION/NEGLECT

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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


Adams HP, Neurology 1999; 53:126-131

NIHSS vs Outcome at 3 months

Kama Guluma, MD


• 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

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

Consideration: the “low NIHSS

score” stroke with a devastating effect

on livelihood

Kama Guluma, MD

The lytic treatment decision

TREATMENT DECISION

NIHSSClinical data

AgeCo-morbidities

Pre-stroke function

Discussion withpatient and family

Kama Guluma, MD

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

The Stroke-focused Neuro ExamBased on the NIHSS

1. Level of consciousness2. Visual fields3. Gaze 4. Facial strength5. Arm strength6. Leg strength7. Limb ataxia (FNF, heel-down-shin)8. Dysarthria9. Sensation (pinch/pinprick)10. Extinction/inattention (bilat sensory) 11. Language (re: aphasia)

LOC

Vision

Motor strength

Coordination

Sensation

Language

Kama Guluma, MD

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

MOTOR SPEECH / LANGUAGE CN / VISUAL LOC

2 / 4 / 8 2 / 4 / 8 2 / 4 / 8 2 / 4 / 8

TOTAL Estimated NIHSS

Grade as:Mild = 2Moderate = 4Severe = 8

From the Foundation for Education and Research in Neurological EmergenciesKama Guluma, MD

Kama Guluma, MD

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

Score Description

6 Dead

5 Severe disability: bedridden, incontinent, and requiring constant nursing care and attention

4 Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance

3 Moderate disability: requiring some help, but able to walk without assistance

2 Slight disability: unable to carry out all previous activities, but able to look after own affairs without assistance

1 No significant disability: despite symptoms, able to carry out all usual duties and activities

0 No symptoms at all

Modified Rankin Scale

Good outcome = score of 0 - 1Kama Guluma, MD

Modified Rankin ScaleStructured 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 EmergenciesKama Guluma, MD

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

Barthel IndexBladder 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 - 100Kama Guluma, MD

Score Description

1 DEAD

2 VEGETATIVE STATE

Unable to interact with environment; unresponsive

3 SEVERE DISABILITY

Able to follow commands/ unable to live independently

4 MODERATE DISABILITY

Able to live independently; unable to return to work or school

5 GOOD RECOVERY

Able to return to work or school

Glasgow Outcome Scale

Kama Guluma, MD

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

1-Year outcome in NINDS trial

38

50

16

13

17

13

28

24

Placebo

t-PA

28

41

24

20

21

15

28

24

Placebo

t-PA

32

43

18

16

22

16

28

24

Placebo

t-PA

Percentage of Patients

Minimal or No Disability Moderate Disability Severe Disability Death

Barthel Index


Glasgow Outcome Scale

Kwiatkowski TG, et al. N Engl J Med. 1999;340:1781-1787.

Kama Guluma, MD

Score Description

6 Dead

5 Severe disability: bedridden, incontinent, and requiring constant nursing care and attention

4 Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance

3 Moderate disability: requiring some help, but able to walk without assistance

2 Slight disability: unable to carry out all previous activities, but able to look after own affairs without assistance

1 No significant disability: despite symptoms, able to carry out all usual duties and activities

0 No symptoms at all


Good outcome = score of 0 - 1Kama Guluma, MD

Looking at NINDS data more closelyThe sliding scale dichotomy endpoint

Saver J, 31st 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” “GOOD”

NIHSS >14

mRS: 0 1 2 3 4 5 6

All NIHSS

“GOOD”

NNT = 9

NNT = 3

Kama Guluma, MD

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

Documents

Stroke Systems and Stroke Scales in the Management of Acute Stroke Patients