Update on Stroke Management

Live from JJ Baumann MS, RN, CNS

Ischemic StrokeFocus on providing treatment quickly!

Patients get treatment faster if :Stroke severity is highArrive by ambulanceArrival during regular hours

Faster treatment times were associated with:

Reduced in-hospital mortality Reduced symptomatic intracranial hemorrhage Increased independent ambulation at discharge Increased discharge to home

Saver et al. Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA. 2013;309(23):2480-2488

Goal door to needle time < 60 minutes

Raising the bar…Meet goal door to needle time in 80% of cases

Ischemic Stroke Treatment

Alteplase – Extending the Window

ECASS 3 extended the time window for tPA…

3-4.5 hour window

Exclusions:• > 80 years old• Taking oral anticoagulants

regardless of INR• Baseline NIHSS > 25• > 1/3 MCA territory has

injury on CT• History of stroke and

diabetesNot FDA approved!

Alteplase and the New Anticoagulants

Direct factor Xa inhibitors – do not use tPA unless not used for more than 2 days or sensitivity tests (aPTT, INR, platelet count, and ECT or TT) are normal

Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trialRaul G Nogueira, Helmi L Lutsep, Rishi Gupta, Tudor G Jovin, Gregory W Albers, Gary A Walker, David S Liebeskind, Wade S Smith, for theTREVO 2 Trialists Lancet 2012; 380: 1231–40

Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised,parallel-group, non-inferiority trialJeffrey L Saver, Reza Jahan, Elad I Levy, Tudor G Jovin, Blaise Baxter, Raul G Nogueira, Wayne Clark, Ronald Budzik, Osama O Zaidat, for theSWIFT TrialistsLancet 2012; 380: 1241–49

Neuro Intervention?

• SWIFT– Primary efficacy outcome recanalisation without ICH – Solitaire 61% vs. Merci 24%, p<0.0001

• TREVO 2– Primary efficacy outcome TICI score 2-3 – Trevo 86% vs. Merci 60%, p<0.0001

Stent retrievers are preferred over MERCI or Penumbra

Ischemic Stroke Blood Pressure

• Hold BP medications unless SBP > 220 or DBP > 120

• Lower 15% in the first 24 hours

Ischemic Stroke - ALIAS

ALIAS - High-Dose Albumin Therapy for Neuroprotection in Acute Ischemic Stroke (M

Ginsberg, MD)

• Use albumin to reduce brain swelling and improve neurologic outcomes.

• Stopped due to frutility.• No benefit.

Ischemic Stroke Prevention

RE-LY Trial: Dabigatran versus Warfarin in Patients with Atrial Fibrillation

Connolly SJ, Ezekowitz MD, et al. NEJM. 2009;361;1-13.

ROCKET AF:Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation

Patel, MR, et al. N Engl J Med 2011; 365:883-891.

ARISTOTLE Trial:Apixaban non-inferior to warfarin in AF patients.

Granger, CB, et al. N Engl J Med 2011; 365:981-992.

Intracranial Hemorrhage

Prothrombin Complex Concentrate (PCC) is preferred over rFVIIa.

Phase 2 trial Promising results:

ICH volume smaller35% reduction in mortalityLess disabilitySlightly more clotting events (e.g. PE’s ,DVT, MI’s)

Phase 3 trialEffectiveNo change in mortality or morbidity

Intracranial Hemorrhage Treatment

• STICH II – early surgery does not increase the rate of death

or disability at 6 months – small but clinically relevant survival advantage for

patients with spontaneous superficial intracerebral hemorrhage without intraventricular hemorrhage.

Mendelow, et al. Early surgery versus initial conservative treatment inpatients with spontaneous supratentorial lobar intracerebralhaematomas (STICH II): a randomised trialLancet. Volume 382, Issue 9890, 3–9 August 2013, Pages 397–408.

Intracranial Hemorrhage Treatment

Minimally Invasive Surgery plus rt-PA for ICH Evacuation (MISTIE)

Less peri-hematoma edema than control group

Effective and safe clot removal

Mould el al. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke. 2013 Mar ;44(3):627-34.

Intracranial Hemorrhage: Blood Pressure

Need enough pressure for injured area to get blood from other vessels

Too much pressure these vessels will burst or bleed more

Intracranial Hemorrhage: Current BP Guidelines

Class IIa Recommendation “In favor of”• SBP 150 – 220 lower SBP to 140Class IIb Recommendation “Less well established”• SBP > 200 or MAP > 150 give IV infusion• SBP > 180 or MAP > 130 ↑ICP monitor ICP,

give intermittent or continuous IV medication• SBP > 180 or MAP > 130 maintain BP 160/90 or

MAP 110 with intermittent or continuous IV medication

Intracranial Hemorrhage: Blood Pressure Trial

Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) II

• Hypothesis: SBP reduction to ≤140 mm Hg reduces the likelihood of death or disability at 3 months after ICH

• Start IV nicardipine within 3 hours of onset of ICH and continue for 24 hours

Subarachnoid hemorrhage

• Early aneurysm repair preferred• Amicar – Early, short course– Avoid antifibrinolytic therapy > 48 post ictus or > 3

days, concern with side effects – Screen for DVT while on

Vasospasm

• Monitor for delayed cerebral ischemia (DCI) in environment with expertise in SAH

• Give Nimodipine 60mg every 4 hours for 21 days

• Detect DCI with TCD, DSA, CTA, EEG, PbtO2

Move to Comprehensive, Multi-disciplinary and Multi-dimensional Stroke Care

Advance Practice Nursing

NeuroIR, Physiatry, Therapist

EVDs, tx of AVM, aSAH

IV tPANeuro

Critical Care

NIR

NSurg Leadership,Care Level

Access to SHC

Patient Outcomes

8 metrics 26 metrics

Meaningful Use

Education to OSH

Research Education/ info sharing

CSC specific resources

Primary Stroke Care Center

Delivering/ Facilitating

Clinical Care

ProgramManagement

Clinical Information

Management

Supporting Self Management

Performance Improvement/ Measurement

Vascular, Rehab,

Stroke RNs

Critical Care Medicine

RadiologyComprehensive Stroke Center

ABCs of Stroke

• Airway• Breathing• Circulation• Disability / DVT• Education• Fever / Food• Glycemic control• Hypo / Hypertension• Imaging

Airway

• Keep NPO until swallow screen performed

• Good oral care

Breathing

• Lung sounds• Oxygen saturation – Use supplemental

oxygen to keep SaO2 > 92%

• Shortness of breath

Circulation

• At least 2 IV sites• Use isotonic solution, not

dextrose, for maintenance fluid

• Coumadin / warfarin• Pradaxa/ Dabigatran

1. What is the goal INR for each?

2. What if the patient has a feeding tube?

Disability / DVT

• Neuro checks• Early mobilization• OOB• Work with rehab– Frozen shoulder– Sitting at edge of

bed–Verbal cues

• SCDs• lovenox• heparin

Education

• Diagnosis• Interventions• Signs of stroke, calling 911• Risk Factors

Risk Factors • HTN• Smoking• Heart disease• cholesterol• xs EtOH• Sedentary life style• DM• AF• Prior stroke or TIA

• Age• Sex• Race• Hereditary

Fever

• Treat fever aggressively– acetaminophen,

ibuprofen – Surface / intravascular

cooling – avoid shivering

• Prevent infection– Aspiration pneumonia– Urinary tract infection

Food

• Oral intake• Feeding tub or PEG• Constipation• Also consider:– Malnourished on admission?– How long do we take to help feed?– Enough calories?

Glycemic Control

• Blood sugar monitoring• HgA1c• How to control?• Avoid the lows!

Hypertension

JNC 7 report. Journal of the American Medical Association. 2003;289:2560-2572.

What to do…

Need Higher

Low perfusion in brain- tight ICA, MCA

Stroke not completed

***Does the neuro exam decline with decreased BP?

Need Lower

Completed their stroke

At risk of bleeding

***Slow and steady!

Imaging

• CT• MRI• TTE• TEE

Stroke Certification for Nurses

Stroke Certified Registered Nurse (SCRN)

American Board of Neuroscience Nursing (ABNN) exam

Through American Association of Neuroscience Nurses

ANVC Certification Exams (NVRN-BC) & (ANVP-BC)

Neurovascular Registered Nurse - Board CertifiedAdvanced Neurovascular Practitioner - Board Certified

Through the Association of Neurovascular Clinicians (ANVC)

Guidelines• Connolly ES Jr.., Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal

subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012;43:1711–37.

• Jauch EC, Saver JL, Adams HP Jr., Bruno A, Connors JJ, Demaerschalk BM, et al.; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947.

• Morgenstern LB, Hemphill JC 3rd., Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010;41:2108–29

• Summers D, Leonard A, Wentworth D, Saver JL, Simpson J, Spilker JA, Hock N, Miller E, Mitchell PH. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke 2009; 40: 2911–44.

Questions?