acute ischemic stroke -...
TRANSCRIPT
Acute Ischemic Stroke
W. David Freeman, MD
Professor of Neurology and Neurosurgery
Mayo Clinic
No conflicts of interest or disclosures
Mayo Clinic Flagler Education Day May 3rd 2019
Acute Ischemic Stroke
Yes
Neurocrit Care. 2015 Dec;23 Suppl 2:S94-102. doi: 10.1007/s12028-015-0159-0.
TISSUE-BASED SELECTION (PENUMBRAL CTP IMAGING DAWN Protocol 6-24hr window)
TIME-BASED SELECTION
Acute Ischemic Stroke
Objectives
• Recognize the signs and symptoms of acute stroke with emphasis on the time of onset to guide therapy
• Know the steps in pre-hospitaland 1st hour evaluation of acute stroke symptoms
• Obtain brain imaging in determining the cause of stroke
• Recognize Time and Tissue-based selection criteria
Stroke
Clinical diagnosis
Sudden onset of neurological deficit that can be explained by vascular cause
Unable to distinguish between a hemorrhagic and ischemic stroke until imaging obtained
Prehospital Evaluation
• Initial prehospital evaluation by EMS:
• History & Physical
• Determine LKW (Last Known Well) or LSN (Last Seen Normal)
• ABC’s
• Glucose check
• Stroke Screen Exam
• Obtain IV access (preferably 16-18g antecubital)
• Call and transport to nearest Stroke Center
ED Evaluation
Checklist
☐ Activate stroke code system (if available)
☐ Vital signs
☐ Maintain oxygen saturation >94%
☐ Determine time of onset / LKW
☐ Determine NIHSS score
☐ CT or other brain imaging study
☐ Medication list
☐ IV access – 18g
☐ Labs: capillary glucose, CBC with platelets, PT/INR, PTT, and beta-HCG
☐ EKG
ABCD2 Score
ABCD2 Criteria Points
Age ≥ 60 years 1
BP ≥ 140/90 mmHg at initial evaluation 1
Clinical Features of the TIA: • Speech Disturbance without
Weakness, or • Unilateral weakness
1 2
Duration of Symptoms: • 10-59 minutes, or • ≥ 60 minutes
1 2
Diabetes Mellitus in Patient's History 1
Transient Ischemic Attack
• Start antithrombotic agent – ASA, clopidogrel, ASA/dipyridamole • Start high-intensity statin (moderate intensity in age >75 yrs) • Carotid Imaging • Consider Transthoracic echocardiogram • Consider 30-day ambulatory cardiac monitor • Encourage smoking cessation
Acute Ischemic Stroke
Yes
TISSUE-BASED SELECTION (PENUMBRAL CTP IMAGING DAWN Protocol 6-24hr window)
Case
• 79 y/o man presents to ED with:
• Left face and arm weakness, neglect
• Onset 1hour ago (witnessed, LSN, LKN)
• PMH: diabetes, hypertension, sleep apnea, hyperlipidemia
• Meds: amlodipine
• Vitals: Afebrile; BP 184/75 mmHg; P 100/min irreg irreg rhythm; RR 18/min; O2sat 100%
• NIHSS 20
• General physical exam unremarkable
• Bedside blood sugar check 120 g/dl
Contraindications for use of IV t-PA
0-3 hrs
AHA/ASA 2013 guidelines 2015 FDA guidelines
Prior stroke within 3 months Removed
Seizure at onset Removed
Bleeding Diathesis Platelet count < 100,000/mm Abnormal PTT on heparin Anticoagulant with INR > 1.7 Current use of DOAC
Bleeding diathesis remains a contraindication, but all laboratory values and specific examples removed
History of ICH Warning for recent ICH
SBP > 185/110 mmHg Remains a warning, but specific BP values removed
Blood glucose < 50 mg/dL (2.8mmol/L)
Removed
Severe Stroke Removed
Mild or rapidly improving symptoms
Removed
Symptoms suggestive of SAH Confirmed SAH
ECASSIII: IV t-PA 3.0 – 4.5
hrs
Additional inclusion between 3 - 4.5 hrs
Meet all criteria of < 3 hour since onset of stroke
Age ≤ 80 years of age
No anticoagulant use, regardless of INR
NIHSS ≤ 25
No combined history of prior stroke and diabetes
Case
• < 3 hours from onset
• NIHSS 20
• Bedside blood sugar check normal
• Noncontrast head CT without hemorrhage
• No contraindications
• BP < 185/110
Neurocrit Care. 2015 Dec;23 Suppl 2:S94-102. doi:
10.1007/s12028-015-0159-0.
IV t-PA Delivery
Two peripheral IV lines (one for TPA, one for PRNs)
Calculate actual body weight
can be estimated by two experienced providers, or scale in ED minus stretcher weight
0.9 mg/kg (MAX 90 mg)
10% given in bolus over 1st minute
The rest given over a 1 hour infusion
Stop immediately if neurological deterioration
Think hemorrhagic conversion
Risk of Intracerebral Hemorrhage with IV t-PA 0-3 hrs
NIHSS Risk of ICH
0-10 2-3%
11-20 4-5%
>20 17%
The higher the NIHSS the higher the risk of ICH
Deterioration During or After IV t-PA
STOP t-PA infusion
Vital signs every 15 mins
Consider non-invasive interventions to lower ICP (e.g., mannitol)
Obtain STAT non-contrast CT scan
Notify the neurosurgeon on call If not available, begin the process of transfer
Stat Labs: PT, PTT, platelets, fibrinogen, type and cross
Give cryoprecipitate if confirmed hemorrhage
Consider one unit of platelets
Endovascular Treatment
Intra-arterial thrombolysis or thrombectomy
• Large vessel occlusion
• Allows later time window of therapy up to 6 – 8 hours
• Continually defining best patient inclusion and exclusion
• Continually developing newer devices
Yes
Neurocrit Care. 2015 Dec;23 Suppl 2:S94-102. doi:
10.1007/s12028-015-0159-0.
TISSUE-BASED SELECTION (PENUMBRAL CTP IMAGING DAWN Protocol 6-24hr window)
Recommendations for Thrombectomy (LVO)
Give IV t-PA if eligible
Endovascular Therapy indicated if the following criteria are met:
Prestroke mRS score 0 to 1
LVO of the ICA or proximal MCA (M1)
Age ≥ 18 (no upper age limit)
NIHSS ≥ 8
ASPECTS score ≥ 6
Groin puncture within 6 hours of LKW
CBF CBV
TTP TTD MTT
CBF= CPP/CVR Thus CBF= CBV/MTT
Neuroimaging Clin N Am.
2011 May ; 21(2): 259–283.
Pre intervention Angio
Post intervention Angio
Red Clot embolus
Freeman WD, Brott TG. Neurovascular Surgery. 2nd Ed. Thieme; 2015. p. 337-350.
Case of Reperfusion Therapy
• Patient NIHSS went from 20 to 3
• Admitted to the ICU for post IV t-PA and endovascular care protocols
Yes
Ischemic Core
• Nonsalvagable tissue (<4min to rescue)
• Electrically silent
• Irreversible damage at cellular level, loss of ion pump function/cellular integrity1
• Core volume closely related to admission neurological deficit2
1 Moustafa R, Baron JC. British J of Pharm 2 Marchal et al 1999. Brain 122 (Pt 12): 2387-2400
Recent Trials: CT Penumbral Selection vs Time-Based Selection or both
More Selective LVO
Small core infarct
Less Selective LVO
MR CLEAN: 13% REVASCAT: 15% THRACE: 11%
EXTEND-IA: 31% SWIFT PRIME: 24% ESCAPE: 25%
Effect size
Late Window Treatment
DWI/PWI and CTP Assessment in the Triage of
Wake-Up and Late Presenting Strokes Undergoing
Neurointervention (DAWN) Multicenter randomized controlled trial, funded by industry
6-24 hours, NIHSS 10+ Perfusion evaluation for core volume, graded by age
Primary outcome: 90 day mRS
Stopped early due to pre-specified endpoint
Endovascular Therapy Following Imaging
Evaluation for Ischemic Stroke 3 (DEFUSE 3) Multicenter randomized controlled trial, funded by StrokeNet
6-16 hours, NIHSS 6+ RAPID software for automated evaluation of penumbra
Primary outcome: 90 day mRS
Completed
TICI- Thrombolysis in Cerebral Infarction “TICI 2B (or better) is where you want to be” (reperfusion)
DEFUSE 3 TICI score Predicts mRS outcome
• Size of core determines
outcome.
• Collaterals determine
core, since patients with
poor collaterals are time
sensitive
• TICI 2B+ determines
outcome
“2B or not 2B”
T. Lesli-Mazwi - DEFUSE 3
Example#1- Core Small, Large Penumbra, not reperfused =Large infarct
Hakimelahi R. Exp Rev C Ther. 7(1),29-28 (2009)
Example #2- moderate core infarct, Large penumbra (salvaged)
Hakimelahi R. Exp Rev C Ther. 7(1),29-28 (2009)
What if I don’t have CT perfusion? Use ASPECTS!–Alberta Stroke Program Early CT Score
Hypodense brain or sulcal edema = 1 point You want to be a perfect 10! ASPECTS > 7 better Outcomes in several Thrombectomy trials
Handoff Checklist ☐ Age, gender, pertinent comorbids
☐ ABC’s
☐ Time of symptom onset
☐ NIHSS pre therapy, post
☐ CT/CTA or MRI/MRA results
☐ IV t-PA administration or contraindication(s) to IV t-PA
☐ Endovascular intervention(s) if applicable, TICI scale if known (recanalization)
Admission/Transfer • Continuous telemetry
• IV normal saline – euvolemia
• Keep glucose 140-180 mg/dl (7.8-10 mmol/L)
• Aggressive fever workup and control
• If t-PA administered,
• no anticoagulation or antiplatelets for 24 hours
• avoid indwelling urinary catheters, nasogastric tubes and intra-arterial catheters for 4 hours-if possible
• Swallow assessment/document before PO!
Conclusion
PMID: 27673305
Remember the Time (<4.5hr) and Tissue-based (Penumbra) Paradigms for acute stroke management (tPA-treated patients and thrombectomy candidates)
Think: Do I have a salvageable penumbra? If so, consider acute endovascular intervention - risk vs benefit:
• LVO time based < 6 - 7.3 hrs (HERMES)
• DAWN 6-24hrs if mismatch still present
Thank you - Sept 26-28th Amelia Island https://ce.mayo.edu/neurology-and-neurologic-surgery/content/11th-annual-stroke-and-cerebrovascular-disease-review-2019