Spotlight

A Stroke of Error

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• This presentation is based on the December 2014AHRQ WebM&M Spotlight Case– See the full article at http://webmm.ahrq.gov – CME credit is available

• Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist Fellowship Program, Mayo Clinic, Jacksonville, FL– Editor, AHRQ WebM&M: Robert Wachter, MD– Spotlight Editor: Niraj Sehgal, MD, MPH– Managing Editor: Erin Hartman, MS

Source and Credits

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Objectives

At the conclusion of this educational activity, participants should be able to:• State the key clinical factors to assess in a patient with

suspected stroke• Appreciate the relationship between elevated blood

pressure and stroke in the acute setting• Identify strategies to compress treatment times for

patients eligible to receive rtPA for acute ischemic stroke• Describe the current timing parameters, risks, and

benefits for rtPA administration in acute ischemic stroke• Define the necessary steps to become certified as a

primary stroke center by The Joint Commission

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Case: A Stroke of Error

A 67-year-old man with a history of untreated hypertension presented to the emergency department (ED) after a fall. On presentation, he was noted to have a systolic blood pressure of 220 mm Hg and word-finding difficulties of unclear duration. Laboratory results were notable for an elevated troponin of 0.2 µg/L and an elevated creatinine of 1.9 mg/dL (but there was no baseline comparison for the latter). To further evaluate his neurologic deficit, the ED obtained a CT scan of his brain without contrast before admitting him to the cardiology service with a working diagnosis of hypertensive emergency. The head CT demonstrated extensive white matter hypoattenuation, which was greater than expected for his age, but no focal findings. The cardiology team ordered an MRI to further characterize these findings, but the patient was unable to tolerate it due to his altered mental status. Neurology was not formally consulted.

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Initial Evaluation in Suspected Stroke

• Rapid and focused assessment is key• Primary elements should include:

– Establishing the time of symptom onset– Establishing the time that the patient was last

neurologically normal (if onset unclear)– Identifying signs of lateralized hemispheric or

brainstem dysfunction – Obtaining a non-contrast head CT

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Initial Evaluation in Suspected Stroke (2)

• The National Institutes of Health Stroke Scale is a validated 15-item scale that assesses key components of the standard neurologic exam

• The elements help create a scoring system that guides assessment of neurologic impairment

• Elements include: level of consciousness, gaze, visual fields, facial palsy, motor arm/leg, limb ataxia, sensory function, language, dysarthria, and extinction and inattention

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Hypertension in Setting of Stroke

• Blood pressure (BP) is commonly elevated in patients with acute stroke and related to stress of cerebral infarction, pre-existing hypertension, or response to increased intracranial pressure

• BP spontaneously declines in most patients within the first 24 hours of admission

• Cerebral, cardiac, or renal dysfunction can also occur in the setting of extreme BP elevations

• At presentation, differentiating between hypertension emergency and acute stroke is not always easy

• Neurologic consultation can be very helpful in ED to get expert examination and input

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Case: A Stroke of Error (2)

Two days into his hospitalization, after spontaneous resolution of his hypertensive emergency and initial neurologic symptoms, the patient became acutely unresponsive and was noted to have new right hand weakness. The cardiology team called a "Code Stroke." The consulting neurology team examined the patient and found dysarthria, aphasia, right arm and face weakness, and a right homonymous hemianopsia. A head CT without contrast again demonstrated white matter hypoattenuation without hemorrhage. The team administered intravenous tPA for presumed ischemic stroke 100 minutes after the acute deficit began. Three hours later, the patient developed new ataxia and nystagmus, prompting an emergent head CT, which demonstrated post-tPA intracerebral hemorrhage in several areas. After careful monitoring and several additional days in the ICU, the patient ultimately was transferred to a rehabilitation facility with moderate persistent neurologic deficits.

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Improving Clinical Outcomes in Stroke

• Outcomes are strongly associated with time to treatment with intravenous rtPA

• Strategies that can compress treatment time for eligible patients include:– Pre-hospital notification of acute stroke teams– Obtaining non-contrast head CT upon ED arrival– Ready availability of rtPA– Written protocols for use of intravenous rtPA

• Key is streamlining systems of care with rapid and coordinated response from providers

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Challenges for Already Hospitalized Patients

• Most systems are well designed for patients arriving to the ED, but these same systems are needed when a patient develops a stroke during hospitalization

• Unique issues include:– Patients may be in diverse locations in the hospital– Immediate neurologic evaluation may be limited– Nursing and other staff on non-neurologic floors may be less

aware and comfortable with assessment and triage protocols– Urgent assessments (labs and imaging) may not occur as

efficiently as from the ED– Availability and use of rtPA may be limited on

medical/surgical units• Development of "in house" stroke protocols may

overcome some of the challenges associated with delayed diagnosis and treatment

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Reviewing the Role of rtPA in Stroke

• Intravenous rtPA is the only FDA-approved treatment for acute ischemic stroke

• An initial randomized control study demonstrated benefit for patients treated within 3 hours of symptom onset– Benefits were greatest for patients treated

within 90 minutes of symptom onset– Symptomatic hemorrhage—the main risk

factor—occurred in 6.4% of treatment group versus 0.6% of placebo group

– Most symptomatic intracerebral hemorrhages occur within 24–36 hours of rtPA administration (as in this case)

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Optimizing Use of rtPA in Stroke

• Strict adherence to inclusion/exclusion criteria is critical to achieve best possible outcomes

• Exclusion criteria may be greater for hospitalized patients who have recently undergone procedures

• Use of novel oral anticoagulants is also posing a challenge in estimating and managing risk/benefits for rtPA use

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Certification as a Primary Stroke Center

• The Joint Commission began providing certification for primary stroke centers as a mechanism to standardize and centralize stroke care in the US

• Basic elements include:– Delivering care to patients with stroke– Offering rtPA and monitoring on stroke unit– Measurement of quality of care (e.g.,

database or registry that tracks volume, treatment timelines and outcomes, etc.)

– Adoption of evidence-based practices– Benchmarking of metrics each year

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This Case

• The patient in this case presented with a likely hypertensive

emergency and while not necessarily an error, earlier neurologic

consultation in the ED may have guided the difficult diagnostic

distinction between hypertensive emergency and acute stroke

• The patient then developed symptoms consistent with an acute

ischemic stroke 2 days into hospitalization

• Treatment protocol with rtPA was initiated and, while unclear if the

patient met true exclusion criteria, he experienced a complication

of intracerebral hemorrhage

• Such outcomes in primary stroke centers would be actively

tracked with a focus on systems to learn from any potential errors

in management (with an eye toward improvement initiatives)

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Take-Home Points

• Timely neurological assessment of patients with suspected stroke increases the probability of identifying patients who may benefit from acute reperfusion therapy

• Written stroke protocols and coordinated acute stroke teams can reduce onset-to-treatment times and facilitate the best possible outcomes for ischemic stroke patients treated with recombinant tissue-type plasminogen activator

• Periodic review of performance metrics and ongoing quality improvement projects can improve stroke systems of care

• Certification of primary stroke centers has proven effective in improving stroke-related outcomes and identifies hospitals that adhere to current evidence-based practices