Stroke and the EDStroke and the ED

Kurian Thomas, MDKurian Thomas, MD

Department of NeurologyDepartment of Neurology

The critical step in strokeThe critical step in stroke

Emergency Department (ED) evaluation Emergency Department (ED) evaluation is key for treatment of acute strokeis key for treatment of acute stroke

Every member of ED staff vital in Every member of ED staff vital in recognition and implementationrecognition and implementation

Step by step processStep by step process tissue plasminogen activator (tPA)tissue plasminogen activator (tPA)

Acute stroke treatmentAcute stroke treatment

About 700,000 strokes annuallyAbout 700,000 strokes annually Small percentage eligible for Small percentage eligible for

thrombolysis, but benefit has been shownthrombolysis, but benefit has been shown Uncommon use = delaysUncommon use = delays Ideal targets for time Ideal targets for time Theraputic nihlismTheraputic nihlism

tPAtPA

Only FDA approved medication Only FDA approved medication fibrin-specific thrombolytic agent that activates fibrin-specific thrombolytic agent that activates

plasminogen to form plasmin, a protease that plasminogen to form plasmin, a protease that cleaves fibrin. cleaves fibrin.

Efficacy in several trials following initial studyEfficacy in several trials following initial study Safety in community hospitals similar to trial Safety in community hospitals similar to trial

centers. Hemorrhage rates of 6%centers. Hemorrhage rates of 6% Inclusion and exclusion criteriaInclusion and exclusion criteria

Inclusion criteria for tPAInclusion criteria for tPA

  Age ≥18 years  Age ≥18 years     Clinical diagnosis of ischemic Clinical diagnosis of ischemic strokestroke

causing a measurable neurologic deficit causing a measurable neurologic deficit Time of symptom onset well established Time of symptom onset well established

to be <180 minutes before treatment to be <180 minutes before treatment would begin would begin

Exclusion criteria Exclusion criteria

1.1.    Evidence of intracranial hemorrhage on     Evidence of intracranial hemorrhage on noncontrast head CT  noncontrast head CT  

  2.2.    Only minor or rapidly improving     Only minor or rapidly improving strokestroke symptoms  symptoms  

  3.3.    High clinical suspicion of subarachnoid     High clinical suspicion of subarachnoid hemorrhage even with normal CT   hemorrhage even with normal CT   

4.4.    Active internal bleeding (e.g., gastrointestinal     Active internal bleeding (e.g., gastrointestinal bleed or urinary bleeding within last 21 days) bleed or urinary bleeding within last 21 days)

Exclusion criteriaExclusion criteria

5.5.    Known bleeding diathesis, including but not     Known bleeding diathesis, including but not limited to:   Platelet count 100,000/mm.  Patient limited to:   Platelet count 100,000/mm.  Patient has received heparin within 48 hours and had has received heparin within 48 hours and had an elevated activated partial thromboplastin an elevated activated partial thromboplastin time (greater than upper limit of normal for time (greater than upper limit of normal for laboratory). Recent use of anticoagulant (e.g., laboratory). Recent use of anticoagulant (e.g., warfarin sodium) and elevated prothrombin warfarin sodium) and elevated prothrombin time >15 seconds   time >15 seconds   

6.6.    Within 3 months of intracranial surgery,     Within 3 months of intracranial surgery, serious head trauma, or previous serious head trauma, or previous strokestroke

Exclusion criteriaExclusion criteria

  7.7.    Within 14 days of major surgery or serious trauma      Within 14 days of major surgery or serious trauma    8.8.    Recent arterial puncture at noncompressible site      Recent arterial puncture at noncompressible site    9.9.    Lumbar puncture within 7 days       Lumbar puncture within 7 days   10.10.  History of intracranial hemorrhage, arteriovenous   History of intracranial hemorrhage, arteriovenous

malformation, or aneurysm   malformation, or aneurysm   11.11.  Witnessed seizure at   Witnessed seizure at strokestroke onset onset 12.12.  Recent acute myocardial infarction     Recent acute myocardial infarction   13.13.  On repeated measurements, systolic pressure <185   On repeated measurements, systolic pressure <185

mm Hg or diastolic pressure <110 mm Hg at time of mm Hg or diastolic pressure <110 mm Hg at time of treatment, requiring aggressive treatment to reduce treatment, requiring aggressive treatment to reduce blood pressure to within these limitsblood pressure to within these limits

Target time framesTarget time frames

Door to physician-10 minDoor to physician-10 min Door to CT completion-25 minDoor to CT completion-25 min Door to CT reading-45 minDoor to CT reading-45 min Door to treatment-60 minDoor to treatment-60 min Access to neurologic expertise-15 minAccess to neurologic expertise-15 min Access to neurosurgical expertise-2 hrAccess to neurosurgical expertise-2 hr

ED proceduresED procedures

notification- prior to arrival or notnotification- prior to arrival or not Triage nurse- suspect strokeTriage nurse- suspect stroke

Immediate Physician NotificationImmediate Physician Notification

ABCHistory

Vital sign monitoringPulse oxIV access

Cardiac monitoringNeurologic monitoring

Neurology consultCALL PHARMACY

Labs Head CT

EKG and CXR

LabsLabs

Rapid blood glucose level. AccucheckRapid blood glucose level. Accucheck CBCCBC Coagulation profileCoagulation profile BMP BMP Type and Screen Type and Screen These results may be sent to transferring These results may be sent to transferring

Neurology team Neurology team

The Lancet NeurologyThe Lancet Neurology - Volume 5, Issue 9 (September 2006)   - Volume 5, Issue 9 (September 2006)  

Early CT changesEarly CT changes

Loss of insular ribbon Loss of insular ribbon Loss of gray-white interface Loss of gray-white interface Loss of sulci Loss of sulci Acute hypo density Acute hypo density Mass effect Mass effect Dense MCA sign Dense MCA sign

rt-PA Treatment Based on CT Findingsrt-PA Treatment Based on CT Findings

      CT FindingsCT Findings      RecommendationsRecommendations

None None Treat Treat

Subtle < 1/3 MCA Subtle < 1/3 MCA Treat Treat

Subtle > 1/3 MCA Subtle > 1/3 MCA Probably Probably treat treat

Hypodensity < 1/3 MCA Hypodensity < 1/3 MCA Probably treat Probably treat

Hypodensity > 1/3 MCA Hypodensity > 1/3 MCA Don’t treat Don’t treat

Give or not give tPAGive or not give tPA

risks of potential benefits of rtPA should be discussed whenever possible with the patient and family

Don’t give to severe stroke (NIH Stroke Scale >22).

BP > 185/110mmHg Lower with IV labetolol 10mg x 2 doses. If not sustained, don’t give tPA

Dose Dose

Intravenous rtPA (0.9 mg/kg; maximum of 90 mg), with 10% of the dose given as a bolus over 1 minute, followed by an infusion lasting 60 minutes

Pharmacy to reconstitute. Don’t wait for all investigations

What nextWhat next

While infusing: While infusing: Monitor for BP elevations and treat with IV Monitor for BP elevations and treat with IV

labetolol (10mg) or IV hydralazine if above labetolol (10mg) or IV hydralazine if above 180/105.180/105.

Monitor for clinical deterioration. If it occurs, Monitor for clinical deterioration. If it occurs, then stop the IV infusion. CT headthen stop the IV infusion. CT head

Monitor for bleeding anywhere.Monitor for bleeding anywhere. No catheters/ feeding tubes after infusing.No catheters/ feeding tubes after infusing.

What nextWhat next

Transfer to hospital with Neurology ICU Transfer to hospital with Neurology ICU service. service.

Contact transferring ED, Neurology Contact transferring ED, Neurology resident and Neurointensive attending on resident and Neurointensive attending on call.call.

Disk of CT scan to be made and sent. Disk of CT scan to be made and sent. Unofficial read if time permitsUnofficial read if time permits

VA ED arranges ambulanceVA ED arranges ambulance