STROKE

STROKE

Presented by Robert Nelson BSN, MBA, MHA, SCRN, CNRN, ONC

Vice President Neuroscience and OrthopedicsHCA East Florida Division

OBJECTIVESOBJECTIVES

Discuss the Risk Factors for Ischemic Stroke

Define two types of stroke ischemic and hemorrhagic

Discuss the Evaluation and Work-up for Ischemic Stroke

including Potential Thrombolytic Candidates

Identify eligible stroke patients for thrombolytic therapy

Identify the Primary steps in the management of Stroke

Secondary prevention of stroke.

Stroke Epidemiology and Risk Factors

Stroke Epidemiology and Risk Factors

StrokeStroke

Stroke is an acute vascular event that affects the brain.

Stroke involves neurological changes caused by an acute interruption of blood supply to a part of the brain.

There are two main types of stroke. The first type is ischemic stroke, which

results from decreased blood flow to a portion of the brain with consequent cell death.

The second type is hemorrhagic stroke, which results from bleeding within the brain.

Stroke FactsStroke FactsStroke FactsStroke FactsA leading cause of death in the United States

795,000 Americans suffer strokes each year

134,000 deaths each year- From 1996 to 2006, the stroke death rate fell 33.5% and number of deaths fell by 18.4%

6,400,000 stroke survivors

Stroke FactsStroke FactsStroke FactsStroke Facts

A leading cause of adult disability

Up to 80% of all strokes are preventable through risk factor management

On average, someone suffers a stroke every 40 seconds in America

Non-modifiable Risk Factors

Non-modifiable Risk Factors

Age

Gender

Race/ethnicity

Heredity

Sacco RL, et al. Stroke. 1997;28:1507-1517.

Women & StrokeWomen & StrokeWomen & StrokeWomen & Stroke

Stroke kills more than twice as many American women every year as breast cancer

More women than men die from stroke and risk is higher for women due to higher life expectancy

Women suffer greater disability after stroke then men

Women ages 45 to 54 are experiencing a stroke surge, mainly due to increased risk factors and lack of prevention knowledge

African Americans & StrokeAfrican Americans & StrokeAfrican Americans & StrokeAfrican Americans & Stroke Incidence is nearly double that of Caucasians

African Americans suffer more extensive physical impairments

Twice as likely to die from stroke than Caucasians

High incidence of risk factors for stroke Hypertension Diabetes Obesity Smoking Sickle cell anemia

Hispanics & StrokeHispanics & StrokeHispanics & StrokeHispanics & Stroke

Higher incidence among Mexican Americans than Caucasians

Mexican Americans are at increased risk for all types of stroke and TIA at younger ages than Caucasians

Spanish-speaking Hispanics are less likely to know stroke symptoms than English-speaking Hispanics, African Americans and Caucasians

Stroke Risk Factors:Modifiable/LifestyleStroke Risk Factors:Modifiable/Lifestyle

Hypertension

Cigarette smoking

Hypercholesterolemia

Hyperlipidemia

Excessive alcohol use

Cocaine and IV drug use

Physical inactivity

Oral contraceptive use

Potentially Treatable or Modifiable

Risk Factors for Stroke

Potentially Treatable or Modifiable

Risk Factors for Stroke Heart disease (MI,

CHF, PFO)

Atrial fibrillation

Prior stroke or TIA

Carotid artery disease

Sickle cell anemia

High RBC count

Diabetes

Menopause

Obesity

Elevated homocysteine level

Low socioeconomic status

Management of Patients with Ischemic Stroke

Management of Patients with Ischemic Stroke

Stabilize the patient - A B C’s

Restore or Improve Blood Flow

Thrombolytic therapy

Prevent recurrent embolism

Maintain collateral flow

Determine location and mechanism of stroke

Prevent stroke complications

Take steps for secondary prevention

Evaluation of StrokeEvaluation of Stroke

History and Physical

Diagnostic tests

Brain parenchyma

Vascular system

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Brain Attack!Brain Attack!Brain Attack!Brain Attack!

Stroke is a “Brain Attack.”

Stroke happens in the brain not the heart

Stroke is an emergency. Call 911 for emergency treatment.

Definition of StrokeDefinition of StrokeDefinition of StrokeDefinition of Stroke Sudden brain damage Lack of blood flow to the brain caused by

a clot or rupture of a blood vessel

Ischemic = Clot (makes up approximately

87% of all strokes)

Hemorrhagic = Bleed- Bleeding around brain

- Bleeding into brain

Embolic Thrombotic

Ischemic vs. Hemorrhagic CVA Ischemic vs. Hemorrhagic CVA Ischemic Stroke

Stepwise deterioration or progressive worsening

Waxing and waning of findings

Focal neurologic signs in the pattern of a single blood vessel

Hemorrhagic CVA Early and prolonged

reduction of consciousness

Prominent headache, nausea, and vomiting

Retinal hemorrhages

Nuchal rigidity

Focal signs may not fit pattern of a single blood vessel

American Heart Association. Heart Disease and Stroke Statistics—2003 Update.

TIATIATIATIA Transient ischemic attack (TIA) is a warning

sign of a future stroke – up to 40% of TIA patients will have a future stroke

Symptoms of TIAs are the same as stroke TIA symptoms can resolve within minutes or

hours It is important to seek immediate medical

attention if you suspect that you are having or have had a TIA

Blood TestsBlood Tests rt-PA Candidates

CBC, blood glucose, chemistry, PT, INR, and PTT

Cardiac Enzymes

Homocystein

Fasting Lipid Profile

HgbA1c

Sickle cell disease

Hypercoagulation work-up

Sedimentation rate

ANA

MRI

CT

Images courtesy of Regional Neurosciences Unit, Newcastle General Hospital, Newcastle, UK.

Evaluation of Brain Parenchyma Evaluation of Brain Parenchyma

Vascular TestsVascular Tests

Noninvasive

CT R/O bleed R/O other conditions Identify early changes that would

indicate poor rt-PA outcome

CTA To identify clots that could be treated

with IA rt-PA

MRI Confirms area of infarct with-in a few

hours of the infarct

Vascular TestsVascular TestsNon Invasive

Carotid Dopplers More specific as to degree of carotid stenosis

MRA Defines the degree of stenosis and areas of

occlusion with the brain and neck

Invasive

Conventional cerebral angiography

Risks (should be < 1% risk of stroke or death)

Measurement of lesions

Evaluation of the Vascular System

Evaluation of the Vascular System

Reprinted with permission from Albers GW, et al. Chest. 2001;119:300S-320S.

Penetrating arterydisease

Flow-reducingcarotid stenosis

Atrial fibrillation

Valve disease

Left ventricularthrombi

Cardiogenicemboli

Aortic archplaque

Carotid plaque witharteriogenic emboli

Intracranialatherosclerosis

Heart TestsHeart Tests

12-Lead ECG

Telemetry

Echocardiography

TTE

TEE

Aortic ArchAortic Arch

Transesophageal echocardiography

From: Siddiqui MA, Holmberg MJ, Khan IA. High-grade atherosclerosis of the aorta. Tex Heart Inst J 2002;29:60-2. Accessed at: texasheartinstitute.org/siddi291.html. Copyright © 2002 Texas Heart Institute.

TREATMENTTREATMENT Thrombolytic therapy ACTIVASE, tPA,

Alteplase

Aspirin

Blood pressure management

Secondary prevention

ASA, antiplatelets

Anticoagulation

Prevention of complications

Rehabilitation

Thrombolytic Therapy Time Is Brain:

Thrombolytic Therapy Time Is Brain:

IV rt-PA approved in 1996

Must be given at a designated Stroke Center

Must follow guidelines for administration

Use of approved protocols, care maps, standard orders

IA rt-PA under investigation

Acute Stroke TreatmentsAcute Stroke TreatmentsAcute Stroke TreatmentsAcute Stroke Treatments

Ischemic stroke (Brain Clot)Clot busting medication: t-PA (Tissue Plasminogen Activator)

Clot-removing devices: Merci Retriever, Penumbra

Hemorrhagic Stroke (Brain Bleed)ClippingCoiling

Current rt-PA Treatment

RecommendationsCurrent rt-PA Treatment

Recommendations Reduce risk of ICH by closely following rt-PA protocol

Time greater than 3 hours – greater than 6 hrs for IA rt-PA

Poor blood pressure control

Wrong dose

Elevated blood sugar

NIHSS Stroke Scale score > 20

rt-PA Inclusion/Exclusion Criteria rt-PA Inclusion/Exclusion Criteria

Age 18 years or older

Symptoms Onset IV rt-PA – 3 hours or less IA rt-PA – 6 hours or less consider for rt-PA

Head CT – Rule Out Bleed

Any concomitant diseases leading to bleeding? Recent MI, Stroke Recent trauma, major surgery Recent Bleeding

Exclusion Criteria – rt-PA

Exclusion Criteria – rt-PA

Medications that might increase bleeding? Anticoagulants

Exam findings – high risk of bleeding Systolic BP > 185 Diastolic BP > 110

Lab findings – high risk of bleeding Prolonged INR, PTT Thrombocytopenia

Exclusion Criteria – rt-PAExclusion Criteria – rt-PA Findings on neurological examination

Very mild Stroke ( NIHSS score < 2-3 ) Very Severe Stroke (NIHSS score > 20)

CT findings Hemorrhage Large Infarction Stroke Looks older than 3 hrs

Current Usage rt-PA Current Usage rt-PA

Under Usage of rt-PA at Stroke Centers: 1% to 3% Under Usage of rt-PA at Stroke Centers: 1% to 3%

Estimate is that 10% of eligible patients should Estimate is that 10% of eligible patients should receive rt-PA receive rt-PA

The most frequent reason rt-PA is not given is The most frequent reason rt-PA is not given is the patient presents outside the 3 hr. windowthe patient presents outside the 3 hr. window

Patient and Community Education CriticalPatient and Community Education Critical

Blood Pressure in Ischemic Stroke

Blood Pressure in Ischemic Stroke

Acute elevations of BP are common in stroke

Often declines spontaneously in first 24 - 48 hours

Seen in 85% of patients

Cerebral autoregulation is defective in most patients

Acutely lowering BP can expand area of ischemia

BP Recommendations for Ischemic Stroke Patients Eligible for ThrombolysisBP Recommendations for Ischemic

Stroke Patients Eligible for Thrombolysis Before rt-PA treatment

Systolic > 185 or diastolic > 110 Labetalol

During and after rt-PA treatment Monitor BP per protocol Diastolic > 140

Nitroprusside Systolic > 230 or diastolic 121 - 140

Labetalol or nicardipine Systolic 180 - 230 or diastolic 105 - 120

Labetalol

Aim for 10%-15% reduction in BP

BP Recommendations for Ischemic Stroke Patients Not Eligible for

Thrombolysis

BP Recommendations for Ischemic Stroke Patients Not Eligible for

Thrombolysis Systolic < 220 or diastolic < 120

Observe unless other end-organ involvement

Systolic > 220 or diastolic 121 - 140

Labetalol 10-20 mg IV over 1 - 2 min (may repeat or double every 10 min)

Nicardipine

Diastolic >140

Nitroprusside

Aim for 10%-15% reduction in BP

rt-PA rt-PA Administer within 60 minutes of ED arrival and

within 3 hour onset window

Total IV dose

0.9 mg/Kg X _____(pt wt in Kg) = _____ mg

Maximum total IV dose = 90 mg over 1 hour

Bolus 10% total IV dose over 1 minute

Then give 90% total IV dose over remaining 60 minutes

TREATMENT /PREVENTION OF COMPLICATIONS

TREATMENT /PREVENTION OF COMPLICATIONS

Blood Sugar Control

Positioning Depends on clinical

situation 30% elevation helps

to prevent aspiration Keeping the patient

flat increases cerebral perfusion but time limited

Bedrest with patients who are susceptible to orthostatic changes

Prevention DVT prophylaxis Aspiration Early Mobilization

Early Mobilization

Depression

Bowel and Bladder Protocol

New TreatmentsNew Treatments Combined IV and IA Thrombolytics

Clot Retrieval Devices

Neuro-protective Agents

Hypothermia

Hyperbaric Oxygen

Surgical OptionsSurgical Options

Decompressive CraniectomyDecompressive Craniectomy Used as a life saving measure for large

hemispheric infarctions

Brain is allowed to swell to decrease ICP and increase perfusion pressure

Portions of the infarcted tissue are resected

Mortality is decreased from 80% to 35%

Outcome is improved

Acute Therapy: ConclusionsAcute Therapy: Conclusions Acute stroke therapy requires a coordinated

and focused approach

IV rt-PA within 3 hours is a safe and effective if protocols are followed

Workup should determine the cause and mechanism of the stroke

Steps to prevent stroke complications can improve outcomes

Stroke RecoveryStroke RecoveryStroke RecoveryStroke Recovery

10% of stroke survivors recover almost completely

25% recover with minor impairments

40% experience moderate to severe impairments requiring special care

10% require care within either a skilled-care or other long-term care facility

15% die shortly after the stroke

Types of Stroke RehabilitationTypes of Stroke RehabilitationTypes of Stroke RehabilitationTypes of Stroke Rehabilitation

Physical Therapy (PT) Walking, range of movement

Occupational Therapy (OT) Taking care of one’s self

Speech Language Therapy Communication skills, swallowing,

cognition

Recreational Therapy Cooking, gardening

Types of Recovery ServicesTypes of Recovery ServicesTypes of Recovery ServicesTypes of Recovery Services

Rehabilitation unit in the hospital

In-patient rehabilitation facility

Home-bound therapy

Home with outpatient therapy

Long-term care facility

Community-based programs

Secondary Prevention of Stroke and Other Vascular Events

Secondary Prevention of Stroke and Other Vascular Events

Secondary PreventionSecondary Prevention Educate the public

One or two education sessions per month

Health fairs BP screening

Cholesterol/triglyceride levels

Serum glucose levels

Presence of A-fib

Lifestyle evaluation

Blood Pressure Control Is Inadequate in the US

Blood Pressure Control Is Inadequate in the US

Arch Intern Med. 1997;157:2413-2446. JNC-IV. Trilling JS, Froom J. Arch Fam Med. 2000;9:794-801.

Millions of People

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13.51623

UnawareUntreatedInadequately treated140/90 mm Hg

Secondary Prevention of Stroke: Percentage Prevented per Year

Secondary Prevention of Stroke: Percentage Prevented per Year

Straus SE, et al. JAMA. 2002;288:1388-1395.

0 2 4 6 8 10 12 14 16 18

% of strokes prevented/yr

AntihypertensivesClopidogrel vs.

ASAWarfarin

Statins

Smoking Cessation

Aspirin

Carotid Endarterectomy

Modifiable Risk Factors and

Preventable Strokes

Modifiable Risk Factors and

Preventable Strokes

Adapted with permission from Gorelick PB. Stroke. 1994;25:220-224.

*Based on 731,000 strokes.

Risk Factor Projected strokes prevented*

Hypertension 360,000

Smoking 90,000

Atrial Fibrillation 69,000

Heavy Alcohol Consumption

34,000

AANN Clinical Practice Guideline Series; Guide to the Care of the Hospitalized Patient with Ischemic Stroke 2nd edition

National Stroke Association; National stroke association.org

Guideline for Healthcare Professionals From the American Heart Association/American :Guidelines for the Early Management of Patients With Acute Ischemic Stroke: American Heart/Stroke Association

Biblography/ References

Biblography/ References