Latest Trends in Care Latest Trends in Care of the Stroke Patient of the Stroke Patient

William J. Meurer, MDWilliam J. Meurer, MDClinical Lecturer and Stroke FellowClinical Lecturer and Stroke Fellow

University of Michigan Stroke ProgramUniversity of Michigan Stroke ProgramDepartments of Emergency Medicine Departments of Emergency Medicine

and Neurologyand Neurology

ObjectivesObjectives

Review concise clinical pearls in Review concise clinical pearls in caring for the acute stroke patientcaring for the acute stroke patient

Review results of past research that Review results of past research that may influence your practicemay influence your practice

Discuss recently announced acute Discuss recently announced acute stroke researchstroke research

Provide overview of ongoing research Provide overview of ongoing research which may influence your practice in which may influence your practice in futurefuture

DisclosuresDisclosures

My salary is provided by the My salary is provided by the University of MichiganUniversity of Michigan

No other financial supportNo other financial support I WILL discuss some off label uses of I WILL discuss some off label uses of

medicationsmedications

OverviewOverview

Review scope and disease process of Review scope and disease process of stroke stroke

Review clinical guidelines and pearlsReview clinical guidelines and pearls Discuss recent advancesDiscuss recent advances Discuss ongoing national and local Discuss ongoing national and local

researchresearch

Stroke Facts

• Third leading cause of death– Over 160,000 deaths per year

• 750,000 strokes per year• Over 4 million stroke survivors• Leading cause of adult disability

– Of those who survive, 90% have deficit

1. Williams GR, J iang J G, Matchar DB, et al. Stroke 1999; 30:2523-28.2. Hoyert DL, Kochanek KD, Murphy SL. National Vital Statistics Report 1999; 47:19.

Annual rate of first cerebral infarction by age, sex and race Annual rate of first cerebral infarction by age, sex and race

(Greater Cincinnati/Northern Kentucky Stroke Study: 1993-94).(Greater Cincinnati/Northern Kentucky Stroke Study: 1993-94). Source: Unpublished data from the GC/NKSS; Kissela et al., Stroke. 2004;35:426-31. Source: Unpublished data from the GC/NKSS; Kissela et al., Stroke. 2004;35:426-31.

Smoothed County Stroke Death Rates: Smoothed County Stroke Death Rates: Adults 35 and Older, 1991-98Adults 35 and Older, 1991-98

Source: CDC. Atlas of Stroke Mortality: Racial, Ethnic and Geographic Disparities in the United States, Jan. 2003

Michigan’s Stroke Belt Michigan’s Stroke Belt

Source : The Atlas of Stroke Mortality

Acute Stroke / ASA GuidelinesAcute Stroke / ASA Guidelines

tPA if indicated and exclusions tPA if indicated and exclusions absentabsent

Anti-platelet within 48 hours (do not Anti-platelet within 48 hours (do not give with tPA)give with tPA)

Permissive hypertensionPermissive hypertension No IV anticoagulants (i.e. heparin) – No IV anticoagulants (i.e. heparin) –

DVT prophylaxis okay (after 48 hr if DVT prophylaxis okay (after 48 hr if tPA given)tPA given)

CT remains standard acute imagingCT remains standard acute imaging

ASA guidelines – ischemic strokeASA guidelines – ischemic stroke

If not receiving thrombolyticsIf not receiving thrombolytics– Do not treat unless SBP > 220 or DBP > Do not treat unless SBP > 220 or DBP >

120120 If receiving thrombolytics treat ifIf receiving thrombolytics treat if

– PreRx SBP > 185 DBP > 110 PreRx SBP > 185 DBP > 110 – PostRx SBP > 180 DBP > 105PostRx SBP > 180 DBP > 105

Doesn’t ACEP also have a Doesn’t ACEP also have a guideline?guideline?

Has practice guidelineHas practice guideline www.acep.org – type acute stroke www.acep.org – type acute stroke

into search boxinto search box I recommend you read it yourselves I recommend you read it yourselves

if interestedif interested

Copied from ACEP website Copied from ACEP website verbatimverbatim

EDs and hospitals should work with EDs and hospitals should work with emergency medical services and the emergency medical services and the community so that all parties know community so that all parties know what the hospital's capabilities are what the hospital's capabilities are regarding acute stroke care.regarding acute stroke care.

Further studies are needed to define Further studies are needed to define more clearly those patients most more clearly those patients most likely to benefit from fibrinolytic likely to benefit from fibrinolytic therapy in acute ischemic stroke.therapy in acute ischemic stroke.

Copied from ACEP website Copied from ACEP website verbatimverbatim

Intravenous tPA may be an Intravenous tPA may be an efficacious therapy for the efficacious therapy for the management of acute ischemic management of acute ischemic stroke if properly used incorporating stroke if properly used incorporating the guidelines established by the the guidelines established by the National Institute of Neurological National Institute of Neurological Disorders and Stroke (NINDS).Disorders and Stroke (NINDS).

Copied from ACEP website Copied from ACEP website verbatim (bolding mine)verbatim (bolding mine)

There is insufficient evidence at this time to There is insufficient evidence at this time to endorse the use of intravenous tPA in clinical endorse the use of intravenous tPA in clinical practice practice when systems are not in place to when systems are not in place to ensure that the inclusion/exclusion criteria ensure that the inclusion/exclusion criteria established by the NINDS guidelines for tPA established by the NINDS guidelines for tPA use in acute stroke are followeduse in acute stroke are followed. Therefore, . Therefore, the decision for an ED to use intravenous tPA for the decision for an ED to use intravenous tPA for acute stroke should begin at the institutional level acute stroke should begin at the institutional level with commitments from hospital administration, with commitments from hospital administration, the ED, neurology, neurosurgery, radiology, and the ED, neurology, neurosurgery, radiology, and laboratory services to ensure that the systems laboratory services to ensure that the systems necessary for the safe use of fibrinolytic agents necessary for the safe use of fibrinolytic agents are in place.are in place.

tPAtPA

A. Hernandez, M.I. Rochera, R. Angles, M. Farre, J. Caballero: Hemorrhagic Transformation And A New Ischemic Accident During Thrombolysis Treatment With rtPA. The Internet Journal of Emergency and Intensive Care Medicine. 2006. Volume 9 Number 1

Acute stroke - summaryAcute stroke - summary

Time is brain (notify, notify, notify)Time is brain (notify, notify, notify) tPA is your friendtPA is your friend Watch for fluctuationWatch for fluctuation Treat feverTreat fever Consider treating hyperglycemiaConsider treating hyperglycemia Use crystalloid (think perfusion)Use crystalloid (think perfusion) Avoid dropping BP in ischemic strokeAvoid dropping BP in ischemic stroke Acute Stroke Protocol in place and Acute Stroke Protocol in place and

ready to go! ready to go!

Important advance – primary stroke Important advance – primary stroke centerscenters

Acute Stroke TeamsAcute Stroke Teams Written Care Protocols Written Care Protocols Emergency Medical ServicesEmergency Medical Services Emergency DepartmentEmergency Department Stroke UnitStroke Unit Neurosurgical ServicesNeurosurgical Services Support of Medical OrganizationSupport of Medical Organization Neuroimaging Neuroimaging Laboratory ServicesLaboratory Services Outcomes/Quality Improvement Outcomes/Quality Improvement Education ProgramsEducation Programs

Primary Stroke Centers (JCAHO)Primary Stroke Centers (JCAHO)Bixby Medical Center

Borgess Medical Center

Bronson Methodist Hospital

Detroit Receiving Hospital/University Health Center

Henry Ford Hospital and Health Network

Herrick Memorial Hospital

Metro Health Hospital

Northern Michigan Hospital

Providence Hospital and Medical Centers

Saint Mary’s Health Care - Grand Rapids, Mich.

Sparrow Hospital

Spectrum Health - Blodgett Campus

Spectrum Health-Butterworth Campus

St. Joseph Mercy Oakland

St. Mary’s of Michigan Medical Center

University of Michigan Health System – MMC

William Beaumont Hospital

Florida Stroke ActFlorida Stroke Act

Required EMS to take patients to Required EMS to take patients to primary stroke centers (JCAHO or primary stroke centers (JCAHO or state certified)state certified)

Resulted in significantly increased Resulted in significantly increased utilization of tPA at certified centersutilization of tPA at certified centers

Resulted in increased stroke volume Resulted in increased stroke volume at certified centersat certified centers

Important Advance – Stroke UnitsImportant Advance – Stroke Units

Outcomes improved (trends)Outcomes improved (trends)– Decreased disabilityDecreased disability– Reduced discharges to nursing homesReduced discharges to nursing homes– Reduced mortalityReduced mortality

Behavior changedBehavior changed– Increased use of tPAIncreased use of tPA

Important advance – Important advance – telemedicinetelemedicine

DisclaimerDisclaimer

Discussion from this point (other Discussion from this point (other than summary) is regarding than summary) is regarding experimental therapiesexperimental therapies

Some of these may be offered to Some of these may be offered to patients at centers in Michigan patients at centers in Michigan currentlycurrently

Some may notSome may not Some may turn out not to work…Some may turn out not to work…

Options other than tPAOptions other than tPA

Intra-arterial tPA (up Intra-arterial tPA (up to 6 hours)to 6 hours)

MERCI retrieval (up to MERCI retrieval (up to 6-8 hours) 6-8 hours)

Either could be Either could be considered in selected considered in selected cases when systemic cases when systemic tPA contra-indicated tPA contra-indicated or outside 3 hr windowor outside 3 hr window

Severity requirementSeverity requirementSource: Imaging Economics, November 2005

MERCI DeviceMERCI Device

Source: St. Petersburg Times, October 2003

Recent Negative ResearchRecent Negative Research

NXY-059 (SAINT II)NXY-059 (SAINT II)– Neuro-protective agentNeuro-protective agent– Primary outcome not reachedPrimary outcome not reached

NovoSevenNovoSeven– Recombinant Factor VIIaRecombinant Factor VIIa– Hemostatic agent (ICH)Hemostatic agent (ICH)– Primary Outcome Not ReachedPrimary Outcome Not Reached– No longer seeking FDA approvalNo longer seeking FDA approval

Activated Factor VIIaActivated Factor VIIa

NXY-059 (SAINT-II)NXY-059 (SAINT-II)

Ongoing Acute Stroke Research at Ongoing Acute Stroke Research at UMHSUMHS

Multi-center Multi-center – CLEARCLEAR– TNKTNK– INSTINCTINSTINCT– NETTNETT

TNK / CLEARTNK / CLEAR

Studying alternate thrombolytic Studying alternate thrombolytic regimens to tPAregimens to tPA

Similar inclusionSimilar inclusion Similar outcome measuresSimilar outcome measures Proposed as potentially safer agentsProposed as potentially safer agents

INSTINCTINSTINCT

Multi-center trialMulti-center trial Targeted educational interventionTargeted educational intervention Involves 24 hospitals in MichiganInvolves 24 hospitals in Michigan Primary endpoint is appropriate use Primary endpoint is appropriate use

of tPAof tPA

NETTNETT

A multi-center network A multi-center network to engage in acute to engage in acute treatment trials in treatment trials in Neurologic Neurologic EmergenciesEmergencies

System of hubs and System of hubs and spokesspokes

U of M is clinical U of M is clinical coordinating centercoordinating center

Henry Ford and Wayne Henry Ford and Wayne State are hubsState are hubs

What is being studied What is being studied elsewhereelsewhere

Encouraging pilot / safety studiesEncouraging pilot / safety studies Highlighting therapies which may Highlighting therapies which may

have impact on acute care in futurehave impact on acute care in future

IMS-2IMS-2

2/3 of standard dose tPA given (0.6 2/3 of standard dose tPA given (0.6 mg/kg)mg/kg)

Cerebral angiogram Cerebral angiogram Additional bolus and infusion at Additional bolus and infusion at

embolism siteembolism site

CLOTBUSTCLOTBUST

Therapeutic hypothermiaTherapeutic hypothermia

Recommended therapy for comatose Recommended therapy for comatose survivors of out of hospital cardiac arrestsurvivors of out of hospital cardiac arrest

Feasibility study done in stroke – further Feasibility study done in stroke – further work ongoingwork ongoing

Prehospital MagnesiumPrehospital Magnesium

Novel system in LA county Novel system in LA county IV magnesium sulfate given to patients IV magnesium sulfate given to patients

identified in the field with severe acute identified in the field with severe acute ischemic strokeischemic stroke

www.fastmag.infowww.fastmag.info

Summary – take home pointsSummary – take home points

Time to treatment is keyTime to treatment is key Treat fever / hyperglycemiaTreat fever / hyperglycemia Permissive HTN in acute ischemic Permissive HTN in acute ischemic

strokestroke There are options beyond 3 hoursThere are options beyond 3 hours A great deal of exciting research is A great deal of exciting research is

going on in Michigan and around the going on in Michigan and around the worldworld

NeurologyLewis B. Morgenstern, MD Director

Devin L. Brown MD, MSMichael M. Wang MD PhD Kate Maddox, RNDarin Zahuranec, MDJennifer Majersik, MDWilliam Meurer, MD

NeurosurgeryJulian T. Hoff, MDB. Gregory Thompson, MD

Emergency MedicineWilliam G. Barsan, MDPhillip A. Scott, MDRobert Silbergleit, MDShirley Frederiksen, MS, BSNAnnette Sandretto, MSNWilliam Meurer, MD

CardiologyKim A. Eagle, MD

EpidemiologyLynda D. Lisabeth PhDMary N. Haan, PhD

RadiologyEllen Hoeffner, MDDheeraj Gandhi, MDJoe Gemette, MD

The University of Michigan Comprehensive Stroke Program

Physical Medicine& RehabilitationLisa DiPonio, MD

University of Michigan Stroke University of Michigan Stroke ProgramProgram

Website – Website – www.med.umich.eduwww.med.umich.edu My email – My email – wmeurer@umich.eduwmeurer@umich.edu Please feel free to contact me if you Please feel free to contact me if you

would like an educational program at would like an educational program at your site!your site!