Management of AcuteManagement of AcuteIschemic StrokeIschemic Stroke
Ethan Cumbler M.D.Ethan Cumbler M.D.Assistant Professor Internal MedicineAssistant Professor Internal Medicine
University of Colorado HospitalUniversity of Colorado HospitalUCH Stroke CouncilUCH Stroke Council
20102010
Disclosures/RelationshipsDisclosures/Relationships Dr. Cumbler serves on the AHA/ASA Pacific/Mountain Stroke Quality Speakers Bureau Dr. Cumbler serves on the AHA/ASA Pacific/Mountain Stroke Quality Speakers Bureau
Dr. Cumbler is the National Stroke Association Dr. Cumbler is the National Stroke Association’’s Course Director fors Course Director forOptimizing Care for In-hospital StrokeOptimizing Care for In-hospital Stroke
No commercial conflict of interests in the last 3 yearsNo commercial conflict of interests in the last 3 years
OBJECTIVESOBJECTIVES
1. Use validated risk stratification tools to determine which TIA patients need admission
3. Identify appropriate means to manage co-morbid illness after stroke
4. Describe mechanisms to reduce the risk of complications following stroke
5. Institute evidence based secondary prevention therapies.
Ischemic StrokeIschemic Stroke700,000 ischemic strokes yearly700,000 ischemic strokes yearly–– Approximately one stroke every 45 secondsApproximately one stroke every 45 seconds
200,000 are recurrent events200,000 are recurrent events
Leading cause of disability in the USLeading cause of disability in the US
Quality stroke care attractive to hospitalsQuality stroke care attractive to hospitals–– Ischemic stroke treated with Ischemic stroke treated with tPA tPA pays extra $6000pays extra $6000
Heart Disease and Stroke Statistics- 2007 Update . Circulation 2007;6:115(5):e69-e171How Diagnosis-Related Group 559 Will Change the US Medicare Cost Reimbursement Ratio for Stroke Centers. Stroke 2007;38:1309-1312Colorado Stroke Alliance Data 2008. Presented by Dr. Don Smith at Rocky Mountain Stroke Summit Dec 2008
Non-contrast Head CT negativeNon-contrast Head CT negative
The patients symptoms begin improving inThe patients symptoms begin improving inthe Emergency Departmentthe Emergency Department
tPA tPA not given due to mild and resolvingnot given due to mild and resolvingsymptomssymptoms
Complete resolution 90 minutes after onsetComplete resolution 90 minutes after onset
Should she be admitted?Should she be admitted?
TIAsTIAs
Within 3 months 10% will have had a strokeWithin 3 months 10% will have had a stroke
Half will occur in the first 48 hoursHalf will occur in the first 48 hours
2/3 of second strokes cause disability2/3 of second strokes cause disability
21% are fatal21% are fatal
Rationale for HospitalizationRationale for Hospitalization1.1. Allows rapid initiation of Allows rapid initiation of tPA tPA for 2for 2ndnd CVA CVA
2.2. Facilitates evaluation and 2Facilitates evaluation and 200 prevention prevention
National Stroke Association GuidelinesNational Stroke Association Guidelines–– Evaluation should occur in 24-48 hoursEvaluation should occur in 24-48 hours
MRIMRICarotid U/SCarotid U/SEchoEchoTelemetryTelemetryLipidsLipids
Antiplatelet ORAnticoagulant
StatinCarotid Endarterectomy
Better outcomes in 1st 2 wks
National Stroke Association Guidelines for the Management of Transient Ischemic Attacks. Ann Neurol 2006;60:301-313
Theoretically This Could OccurTheoretically This Could OccurOutpatientOutpatient…………
Three fourths of Three fourths of TIAs TIAs in the ED are sent homein the ED are sent home–– Subsequent delays in evaluationSubsequent delays in evaluation–– 1/3 not discharged on 1/3 not discharged on antithromboticantithrombotic
Only 2% of Only 2% of TIAs TIAs seen in clinic are admittedseen in clinic are admitted–– Less than half with Less than half with afib afib started on started on warfarinwarfarin–– 1/3 did not have workup for > 30 days1/3 did not have workup for > 30 days
Hospitalization associated with decreased risk ofHospitalization associated with decreased risk ofsecond stroke (HR 0.73)second stroke (HR 0.73)–– But increases resource utilizationBut increases resource utilization
Management and Outcomes of Transient Ischemic Attacks in Ontario. CMAJ 2004; 170:1099-104New Transient Ischemic Attack and Stroke: Outpatient Management by Primary Care Physicians. Arch Intern Med 2000;160:2941-2946The High Risk of Stroke Immediately After Transient Ischemic Attack: A Population Based Study. Neurol 2004;62:2015-2020
Predicting Early Second StrokePredicting Early Second Stroke
ABCDABCD22 Score Score
1110-59 min10-59 min
11PresentPresentDiabetesDiabetes
22> 60 min > 60 min ORORDurationDuration
11SpeechSpeechImpairmentImpairment
22UnilateralUnilateralWeakness Weakness OROR
Clinical DeficitClinical Deficit
11SBP SBP >> 140 140 ororDBP DBP >> 90 90
Blood PressureBlood Pressure
11>> 60 years 60 yearsAgeAge
PointsPointsClinical FeatureClinical Feature
Validation and Refinement of Scores to Predict Very Early Stroke Risk after Transient Ischaemic Attack. Lancet 2007;369:283-92
Predicting Early Second StrokePredicting Early Second StrokeABCDABCD22 Score Score
8.1%8.1%4.1%4.1%1%1%2 day stroke2 day strokeriskrisk
HighHighIntermediateIntermediateLowLowRiskRiskStratificationStratification
6-76-74-54-50-30-3ABCDABCD22
ScoreScore
Low Risk-Low Risk- Outpatient Evaluation Outpatient Evaluation
Intermediate Risk-Intermediate Risk- Inpatient, Hospital Observation, or Outpatient Evaluation Inpatient, Hospital Observation, or Outpatient Evaluation
High Risk-High Risk- Hospitalize Hospitalize
Day after hospitalization she wakesDay after hospitalization she wakesfrom nap with right from nap with right hemiplegia hemiplegia andandaphasiaaphasia–– Last documented normal at noonLast documented normal at noon
Nurse calls the physician listed onNurse calls the physician listed onadmission orders.admission orders.–– No answer after three attempts.No answer after three attempts.–– Nursing eventually determines the correctNursing eventually determines the correct
physician to call.physician to call.
Physician evaluates and orders non-Physician evaluates and orders non-contrast head CTcontrast head CT
4:00 pm4:00 pm
4:30 pm4:30 pm
4:40 pm4:40 pm
Case Continued
Head CT read as negative for bleed.Head CT read as negative for bleed.Based on continued symptomsBased on continued symptoms–– Neurology called for consultation.Neurology called for consultation.
Neurologist explains that she isNeurologist explains that she iscovering multiple hospitals and can notcovering multiple hospitals and can notphysically see the patient.physically see the patient.–– Recommends MRI with diffusion.Recommends MRI with diffusion.
MRI/MRA orderedMRI/MRA ordered
5:005:00
5:105:10
5:155:15
Radiology indicates MRI no longerRadiology indicates MRI no longeravailable as technician has goneavailable as technician has gonehome.home.
Changed to CT perfusion /CTAChanged to CT perfusion /CTA
Read as L MCA clot withRead as L MCA clot withdownstream infarctdownstream infarct
5:205:20
5:255:25
5:455:45
Did this represent exceptional care, standard care, orDid this represent exceptional care, standard care, orsub-standard care?sub-standard care?
TreatmentTreatment
Time ThresholdsTime Thresholds–– Previously 3 hours for IV thrombolysisPreviously 3 hours for IV thrombolysis
ASA now recommends 4.5 hours based on ECASS IIIASA now recommends 4.5 hours based on ECASS III
–– 6 hours for IA thrombolysis6 hours for IA thrombolysis
–– 8 hours for mechanical thrombolysis8 hours for mechanical thrombolysis
1. Del Zoppo GJ et al. Expansion of the Time Window for Treatment of Acute Ischemic Stroke with IV tPA. Stroke 2009;40:2945-482. Adams et al. Early Management of Adults with Ischemic Stroke. Stroke 2007;38:1655-17113. Hacke W, et al. Thrombolysis with Alteplace 3 to 4.5 hrs after Acute Ischemic Stroke. NEJM 2008;359:1317-13294. Lansberg MG et al. Efficacy and Safety of tPA 3 to 4.5 hours after Acute Ischemic Stroke. Stroke 2009;2438-2441
Time to Evaluation for In-HospitalTime to Evaluation for In-HospitalStrokesStrokes
1993 study1993 study–– Median time from recognition to neurologyMedian time from recognition to neurology
evaluation of 2.5 hoursevaluation of 2.5 hours
Albers. Evaluation Times for Patients with In-hospital Strokes. Stroke 1993;24:1817-1822
Admittedly this was 1993Admittedly this was 1993—— prior to the t-PA era prior to the t-PA era
How Are We Doing Now?
Quality of CareQuality of CareEvaluation Time for In-Hospital StrokeEvaluation Time for In-Hospital Stroke
Goal is 25 minutes to CT scanGoal is 25 minutes to CT scan
In the Modern Era:In the Modern Era:
In only 25% was neurology In only 25% was neurology eval eval considered an emergencyconsidered an emergency
Only 15% evaluated by MD within 3 hrs of symptomsOnly 15% evaluated by MD within 3 hrs of symptoms
Only 3% of pts received imaging within benchmark 25 minOnly 3% of pts received imaging within benchmark 25 min
1. Dulli D. Neuroepidemiology 20072. Alvaro LC.. Neurologia 20083. Farooq MU. Cerebrovasc Dis 2008
Education of all staff on stroke symptomsEducation of all staff on stroke symptoms
Any staff member can trigger a stroke alertAny staff member can trigger a stroke alert
Single alert numberSingle alert number
Rapid mobilization of staffRapid mobilization of staff–– Acute Stroke Team or stroke trained Rapid Response TeamAcute Stroke Team or stroke trained Rapid Response Team–– Authority to proceed with evaluationAuthority to proceed with evaluation
Inpatient Inpatient ““Stroke AlertStroke Alert”” Program Program““Code GrayCode Gray””
““Code StrokeCode Stroke””““Code Code NeuroNeuro””
““Code Brain AttackCode Brain Attack””
1. Nolan S. Crit Care Nurs Q 2003
Improving Hospital ProcessesImproving Hospital ProcessesIn-hospital Stroke Evaluation TeamIn-hospital Stroke Evaluation Team
271
74
0
50
100
150
200
250
300
Minutes
Year Before Intervention Year After Intervention
Evaluation Time for In-hospital Ischemic Strokes
1. Cumbler EC. J Stroke and Cerebrovasc Dis in press
Our Patient Has now SufferedOur Patient Has now Sufferedan Ischemic Stroke Followingan Ischemic Stroke Following
Her TIAHer TIA
How can we reduce the chance ofHow can we reduce the chance ofcomplications which would riskcomplications which would risksurvival and promote disability?survival and promote disability?
Management of Co-morbiditiesManagement of Co-morbiditiesGlycemic ControlGlycemic Control
Hyperglycemia present inHyperglycemia present in1/3 of strokes1/3 of strokes
Correlates with worsenedCorrelates with worsenedoutcomesoutcomes
Recommendation is toRecommendation is tocontrol to <200 with goalcontrol to <200 with goalof 80-140of 80-140
How to achieve this goalHow to achieve this goaland whether intensiveand whether intensiveinsulin drip therapy willinsulin drip therapy willend up proving beneficialend up proving beneficialis not clearis not clear
PEARLSPEARLSRarely a need forRarely a need fordextrose in IVF in the firstdextrose in IVF in the first24 hours24 hours
Metformin Metformin problematic-problematic-contrast/lactic acidosiscontrast/lactic acidosis
Sulfonylurea medicationsSulfonylurea medicationsassociated withassociated withhypoglycemia when oralhypoglycemia when oralintake interruptedintake interrupted
MManagement of Co-morbiditiesanagement of Co-morbiditiesHypertensionHypertension
Ischemic PenumbraIschemic PenumbraZone of at risk tissue susceptible to reductionZone of at risk tissue susceptible to reductionbelow the threshold of viability in response tobelow the threshold of viability in response torelatively small drops in MAP.relatively small drops in MAP.
Objective ofObjective ofBlood Pressure ControlBlood Pressure Control
MaximizeMaximizeperfusion toperfusion tothe ischemicthe ischemicpenumbrapenumbra
Minimize theMinimize thehypertensivehypertensiverisk ofrisk ofhemorrhagichemorrhagictransformation.transformation.
Management of Co-morbiditiesManagement of Co-morbiditiesAcute Blood Pressure ControlAcute Blood Pressure Control
80% of stroke admissions have elevated BP.80% of stroke admissions have elevated BP.
Even without intervention, the pressure tendsEven without intervention, the pressure tendsto fall 10-15% in the first 24 hours.to fall 10-15% in the first 24 hours.
By day 10 BP will fall 13-20%By day 10 BP will fall 13-20%
Ischemic Stroke Pre-tPAIschemic Stroke Pre-tPA
Recommended Steps:Recommended Steps:
LabetalolLabetalol 10-20mg IV 10-20mg IV
(may repeat x1) or(may repeat x1) or
NitropasteNitropaste 1-2 inches 1-2 inches
BP must be <185/110 for tPA.
Post-Post-tPAtPA
Monitor BP closely.Monitor BP closely.
BP q15min x 2 hrs thenBP q15min x 2 hrs then
q30min x 6 hrs then q30min x 6 hrs then
qhr x 16 hrs qhr x 16 hrs
Goal BP<180/105
About 1/3 of patients who receive tPA require antihypertensive therapy in the first day.
Choice of agent?NitroprussideLabetololNicardipineFenoldopanNitroglycerin
Avoid sublingual nifedipine and clonidine
Ischemic Stoke Without tPAIschemic Stoke Without tPA
TitratableTitratable
Avoid overcorrectionAvoid overcorrection
If BP lowered it is generally safe as longIf BP lowered it is generally safe as longas not exceeding 10-15%as not exceeding 10-15%
Withhold treatment until BP >220/120
Blood Pressure
““Permissive HypertensionPermissive Hypertension””
Lower targets being investigatedTiming of initiation of antihypertensive therapy controversial
Potter J et al. Controlling hypertension and hypotension immediately post-stroke (CHHIPS) Lancet Neurology 2009;8:48-56
Chronic Blood PressureChronic Blood PressureControlControl
UK TIA study demonstrated a 28%UK TIA study demonstrated a 28%decrease in long term stroke risk fordecrease in long term stroke risk forevery 10mm drop in systolic BP.every 10mm drop in systolic BP.
By comparison- How much riskBy comparison- How much riskreduction do you get with aspirin?reduction do you get with aspirin?
15%15%
ComplicationsComplications64% of stroke patients in a modern stroke64% of stroke patients in a modern strokeunit have a complication in the first weekunit have a complication in the first week–– Fever 24%Fever 24%
–– UTI 16%UTI 16%
–– Pneumonia 11%Pneumonia 11%
–– Myocardial injury 16%Myocardial injury 16%
–– PE 0.6%PE 0.6%
Urinary Tract InfectionUrinary Tract Infection
80% of 80% of nosocomial UTIs nosocomial UTIs are associated withare associated withcatheterscatheters
Infection is directly related to duration of useInfection is directly related to duration of use
Remove ASAP/use alternatives if possibleRemove ASAP/use alternatives if possible
Physicians unaware of catheterPhysicians unaware of catheter–– 28% of cases28% of cases
Aspiration PneumoniaAspiration Pneumonia
__ to > to >__ of stroke patients have dysphagia of stroke patients have dysphagia
One third of patients with aspiration will developOne third of patients with aspiration will developpneumoniapneumonia
50% reduction in risk with formal program:50% reduction in risk with formal program:
Swallow screen prior to diet/medsSwallow screen prior to diet/meds
Aspiration precautionsAspiration precautions
Oral careOral care
Pneumonia/Influenza vaccinePneumonia/Influenza vaccine
Deep Venous ThrombosisDeep Venous Thrombosis
Without prophylaxis, up to 75% of patientsWithout prophylaxis, up to 75% of patientswith hemiplegic stroke will have evidence ofwith hemiplegic stroke will have evidence ofDVTDVT
Effective prophylaxis can reduce the VTEEffective prophylaxis can reduce the VTErate by 50-70%rate by 50-70%
With prophylaxis- 1% symptomatic VTE rateWith prophylaxis- 1% symptomatic VTE rateSherman DG et al. The efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of venous thromboembolism after acute ischaemic stroke (PREVAIL study): an open-label randomized comparison. Lancet 2007;369:1347-1355Sherman DG, Prevention of Venous Thromboembolism, Recurrent Stroke, And Other Vascular Events After Acute Ischemic Stroke: The role of Low-Molecular-Weight Heparin and Antiplatelet Therapy. Journal of Stroke and Cerebrovascular disease 2006;15:250-259
Deep Venous ThrombosisDeep Venous ThrombosisStockings and Stockings and SCDsSCDs- non-significant reduction- non-significant reduction
Anti-platelet therapy alone is NOT sufficient Anti-platelet therapy alone is NOT sufficient
Lower potency heparin prophylaxis (heparinLower potency heparin prophylaxis (heparin5000 U bid) less effective than higher potency5000 U bid) less effective than higher potency
Higher efficacy prophylaxis does not appear toHigher efficacy prophylaxis does not appear toconfer increased risk for ICHconfer increased risk for ICH–– Studies have mixed results on this issueStudies have mixed results on this issue
Mazzone C, et al. Physical Methods for Preventing Deep Vein Thrombosis in Stroke. Cochr Database Syst Review 2004;(4):CD001922.
Vergouwen MD et al. Venous Thromboembolism prophlaxis and Treatment in Patients with Acute Stroke and Traumatic Brain Injury. Curr Opin Crit Care2008;14:149-155
Sherman DG. The efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of venous thromboembolismafter acute ischaemic stroke (PREVAIL study): an open-label randomized comparison. Lancet 2007;369:1347-1355http://www.jointcommission.org/NR/rdonlyres/C9A8B113-070E-4AA0-8FB6-8EF50EB02406/0/F_Section4.pdf
Work-up reveals:Work-up reveals:-LDL 120-LDL 120
-Sinus rhythm-Sinus rhythm-Heart structures normal-Heart structures normal
- <50% - <50% stenosis stenosis of both carotidsof both carotids
Non-Non-cardioembolic cardioembolic strokestrokeoccurring on aspirin 81 mg/dayoccurring on aspirin 81 mg/day
How do we optimize herHow do we optimize herchances of avoiding anotherchances of avoiding another
stroke?stroke?
Lipid ManagementLipid Management
SPARCL trial 16% RRR withSPARCL trial 16% RRR withstatin statin over 5 yrs following CVAover 5 yrs following CVA
No change in mortalityNo change in mortality
Small increase in hemorrhagicSmall increase in hemorrhagicstrokes*.strokes*.
High-dose, high-potencyHigh-dose, high-potencycholesterol lowering therapycholesterol lowering therapyrecommended for LDL>100recommended for LDL>100–– Optional goal of <70Optional goal of <70
Secondary PreventionSecondary PreventionAnti-thrombotics-101Anti-thrombotics-101
JCAHO requires anti-thrombotics to beJCAHO requires anti-thrombotics to bestarted within 48 hoursstarted within 48 hours
Warfarin for atrial fibrillationWarfarin for atrial fibrillation
Antiplatelet therapy if non-cardioembolicAntiplatelet therapy if non-cardioembolic–– ClopidogrelClopidogrel
–– ASA/ASA/Dipyridamole Dipyridamole ERER
–– ASAASA
PRoFESSPRoFESSNo difference in strokesNo difference in strokesbetween between Clopidogrel vsClopidogrel vsASA/ASA/DipyridamoleDipyridamole
–– Increased hemorrhage inIncreased hemorrhage inASA/ER-ASA/ER-DipyriamoleDipyriamole
–– Clopidogrel Clopidogrel better toleratedbetter tolerated
Secondary PreventionSecondary PreventionAnti-thrombotics-201Anti-thrombotics-201
Acute use of heparin has never been proven toAcute use of heparin has never been proven toimprove outcomes.improve outcomes.–– early second ischemic stroke equally balanced byearly second ischemic stroke equally balanced by early hemorrhagic strokes early hemorrhagic strokes
Higher doses of aspirin do not provide greaterHigher doses of aspirin do not provide greaterbenefit than low doses- benefit than low doses- UK TIA trialUK TIA trial
For arterial strokes- For arterial strokes- warfarin warfarin is not superior tois not superior toaspirin- aspirin- WARSS TrialWARSS Trial
Combination of Combination of clopidogrel clopidogrel and aspirin does notand aspirin does notprovide benefit over provide benefit over monotherapymonotherapy- - MATCH TrialMATCH Trial