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STROKE: RESIDENT – Brain Matters

Module VI1. Acute care of ischemic stroke 2. Primary prevention3. Secondary prevention4. Resources for adherence to ischemic stroke guidelines

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1. Identify recommendations for treatment of acute ischemic stroke including t-PA and primary and secondary prevention

2. Describe MMC Stroke Service operations, rationale for focus on stroke and tools available to help providers adhere to AHA stroke care guidelines

3. Identify educational resources for stroke that will provide more in depth information

Learning objectives:

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Why should stroke be a clinical area of focus?

Nationally, stroke is the 3rd largest cause of death

Leading cause of permanent disability for the 700,000 Americans who suffer a stroke annually

MMC cares for 425+ inpatients with stroke annually

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Primary Stroke Center criteria and certification by JCAHO

Improve awareness and availability of optimal acute stroke care

Implement secondary stroke preventionContinuous monitoring of quality

measures to improve outcomes

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Timing is critical!! The time window for treatment of patients with acute

ischemic stroke is narrow IV-Thrombolysis (t-PA) is the recommended treatment

within 3 hrs after ischemic stroke onset though benefit may be present up to 4.5 hrs Earlier therapy is associated with better outcome IV t-PA is not recommended when the time of onset

of stroke cannot be ascertained reliably Acute intracranial vessel occlusion may be treated with

intra-arterial therapy (in a 6 hr window) or Merci retrieval in selected patients

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Emergency diagnostic tests CT head to differentiate between ischemia and

hemorrhage Vascular imaging (CTA, ultrasound) for information

about the vessel patency if indicated and only IF administration of t-PA will not be delayed. If CTA indication MUST BE documented.

Evaluation of physiological parameters (HR, BP, pulse oximetry)

CBC, CMP ECG

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IV t-PA Compared with placebo, treatment with t-PA nearly

doubles the odds of recovery to independent function at 3 months after stroke and beyond

~47% of patients treated with t-PA will return to all pre-stroke physical, social and occupational functions, compared with 27% of those not treated

Rate of risk for symptomatic ICH after t-PA is 6.4%

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Question #1A 71-year-old man presents to the ED at the instruction of his PCP. This manfelt well when he went to bed at midnight but awoke at 8:00 a.m. with leftupper-extremity weakness and numbness. He called his physician who told himto go to the ED. He arrives at the ED at 9:00 a.m. The patient's PMHx includeshypertension and hyperlipidemia for which he takes a Thiazide diuretic and astatin. His BP is 178/92 mm Hg; P/E reveals mild left-sided neglect, a mild leftcentral facial palsy, mild LUE and LLE weakness, and a mild left hemi sensorydeficit. CBC, BMP are normal. CT scan of the brain is normal.

1. Which of the following is the most appropriate next step in this patient's management?

a) Start aspirin b) Start intravenous heparin c) Start clopidogrel d) Start intravenous tissue Plasminogen activator e) Lower blood pressure to 140/90 mm Hg

MKSAP 14

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Question #1: Acute treatmentAnswer: A

This patient had an acute ischemic stroke in the right MCA territory. The time of onset is unknown, but he was last known to be well at midnight, and he is therefore not eligible for intravenous thrombolytic therapy, which is indicated if therapy is started within 3 hours of onset of stroke symptoms or when the patient was last known to be well.

Early administration of aspirin, 160 to 325 mg daily, results in a modest reduction in the risk of recurrent stroke in the short term, and slightly less death and disability in the long term.

Early administration of parenteral anticoagulants has no net benefit for patients with acute stroke. Clopidogrel is not beneficial as acute stroke therapy.

Early blood pressure lowering is not recommended for most patients with acute stroke unless they are being considered for thrombolytic therapy or are suffering from a concomitant myocardial infarction or aortic dissection. In such cases, some experts aim for a target mean arterial pressure of 140 mm Hg, though without definitive evidence that this is beneficial.

MKSAP 14

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t-PA inclusion criteria:Inclusion Criteria:Clinical diagnosis of stroke Age 18 or olderTime of stroke onset (i.e. last time pt

witnessed to be well) < 3 hours BP Systolic <= 185, diastolic <= 110 (can

receive 1-3 doses of BP agent for control) Pro time <= 15 seconds or INR <= 1.7 Platelet count >= 100,000 Blood Glucose => 50 and <= 400 mg/dl

Modified from NINDS criteria

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t-PA exclusion criteria:Exclusion Criteria: Minor stroke or rapidly resolving stroke (controversial) Heparin treatment during the past 48 hours with an elevated

PTT Evidence of acute myocardial infarction Relative Contraindications: History of prior intracranial hemorrhage, neoplasm, AVM or

aneurysm Major surgical procedures within 14 days Stroke or serious head injury within 3 months Seizure at onset of stroke Gastrointestinal or urinary bleeding within last 21 days Lactation or Pregnancy within 30 days

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t-PA dose and administrationTissue Plasminogen Activator (t-PA)

Alteplase (Activase®)

Onset of action occurs in 60-90 minutes

LOADING dose = 0.09 mg/kg IV push over 1 minute (dose not to exceed 9 mg)

Followed by: INFUSION dose = 0.81 mg/kg IV infusion over 1 hour (dose

not to exceed 81 mg)tPa dose calculator and NIHS Scale are accessed through use of the ED stroke order set

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The Mainstays of Acute Treatment Treatment and stabilization of general conditions Specific therapy, either recanalization of a vessel occlusion or

prevention of mechanisms leading to neuronal death in the ischemic brain

Prophylaxis and treatment of complications Hemorrhagic transformation, space-occupying edema Seizures Aspiration Infections pressure ulcers deep vein thrombosis or pulmonary embolism

Early secondary prevention Early rehabilitation

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Acute treatment Aspirin

Small but significant reduction in death and dependency and recurrence of stroke

In a combined analysis, the reduction in death and dependency during the first 2 weeks was 1%

Anticoagulation (heparin or LMWH) Not routinely used but selected patients may benefit

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Blood Pressure Recommendations: Immediate antihypertensive therapy for moderate HTN is

recommended in case of stroke but should be applied cautiously (preservation of ischemic penumbra)

Recommended BP targets with prior HTN: 180/100-105 mmHg without prior HTN: 160-180/90-100mmHg After thrombolysis: keep BP <180/105 mmHg

Recommended drugs: IV: Labetalol, sodium nitroprusside or NTG; orally: captopril

Avoid nifedipine and any drastic BP decrease Avoid and treat hypotension particularly in unstable patients

by administering adequate amount of fluids and when required, volume expander and or catecholamine

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Acute treatment ~ Other considerations

24 hour telemetry treat fever and its cause when temp reaches 37.5◦C

Fever negatively influences neurological outcome after stroke Experimentally, fever increases infarct size

electrolyte abnormalities: rare after ischemic stroke but frequent after ICH and SAH balanced electrolyte and fluid status are important to avoid:

hypo/hypervolemia, plasma volume contraction and raised hematocrit

glucose High glucose levels in acute stroke increase the size of the

infarction and reduce functional outcome Hypoglycemia worsens outcome as well

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Other Recommendations:

● Continuous cardiac monitoring in the first 24 hrs.

● Oxygenation monitoring● O2 administration in case of hypoxemia

ABG or O2 sat <92%

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Primary PreventionPrimary Prevention

High blood pressure Atrial fibrillation Diabetes Mellitus Carotid artery disease Myocardial infarction Hormone replacement

therapy Migraine

High cholesterol Hyper-homocysteinemia Smoking Heavy alcohol use Physical

inactivity/obesity

Conditions and lifestyle factors identified as a risk for stroke:

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Primary Prevention: Atrial fibrillationAverage stroke rate in a pt with AF =

5%/year Warfarin reduces the rate by 60-70% with an

INR between 2-3 (INR <2.0 is not effective)ASA (300 mg) results in a relative risk

reduction of 21%Use CHADS score to determine need for

anticoagulationPatients with contraindications to

anticoagulant therapy should be offered ASA

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Primary Prevention: asymptomatic internal carotid (ICA) stenosisManagement is controversialPerforming carotid Endarterectomy (CEA) in

asymptomatic carotid stenosis >60% offers an absolute RR of 5.9-12.6% over 5y NNT = 8-17

In order to have benefit, the surgical risk must not exceed 3%

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Question #2A 64-year-old man is evaluated because he lost vision in the lower field of his

right eye for about 10 minutes yesterday. He wants a referral to see an ophthalmologist. His medical history includes hypertension and he is a former smoker. His medications are aspirin and enalapril. BP is 142/90 mm Hg. P/E is normal. Carotid ultrasonography reveals 70% to 80% stenosis of the right internal carotid artery and 80% to 90% stenosis of the left internal carotid artery. He has no known contraindications to carotid intervention.

2. Which of the following is the most appropriate next step in the management of this patient?

a) Right carotid Endarterectomy b) Left carotid Endarterectomy c) Switch aspirin to Warfarin d) Add clopidogrel to aspirin e) No change in therapy

MKSAP 14

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Question #2 : Secondary PreventionAnswer: A

The right internal carotid artery is stenotic and symptomatic, having caused partial transient monocular blindness (amaurosis fugax) with a typical loss of vision in either the upper or lower half of one eye. The benefit of carotid intervention is far greater for symptomatic than asymptomatic stenosis, regardless of the degree of stenosis. Carotid Endarterectomy remains the standard intervention, and is most beneficial when performed within the first few weeks after initial symptoms. Carotid angioplasty and stenting are still under investigation and are not recommended for patients who are good candidates for surgical Endarterectomy, except in the context of a randomized clinical trial.

Switching from aspirin to Warfarin has never been shown to be of benefit.

Adding clopidogrel to aspirin increases the risk of major bleeding without any additional benefit.

MKSAP 14

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Secondary Prevention ASA :13% relative risk reduction for stroke after TIA

or stroke Incidence of GI disturbances is dose dependent No difference in effectiveness amongst low

(<160mg), medium (160-325) or high (500-1500mg) dose aspirin

Dipyridamole and ASA (Aggrenox): Yields a modest risk reduction, 1% per year

Clopidogrel (Plavix): Not more effective than ASA unless patient has multiple vascular bed (CAD, PVD) disease. Combination ASA/clopidogrel for stroke indications cannot be recommended routinely

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Secondary PreventionBlood pressure, lipid, and Diabetes mellitus

control effectively reduces vascular recurrence rates in all vascular bedsKeep SBP < 140 and DBP < 90; in those

with diabetes or chronic renal disease SBP <130 and

DBP <80Keep HgbA1C <7

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(ATP) Adult Treatment Panel III Classification of:(LDL) low density lipoprotein, (HDL) high density lipoprotein cholesterol, and totalLDL-primary target of therapy ° <100 °100-129 °130-159 °160-189 °≥190

Total cholesterol °<200 ° 200-239 °≥240

HDL cholesterol °<40 °≥60

Optimal° Near/above optimal° Borderline high° High° Very high

° Desirable° Borderline high° High

° Low° High

US Dept. of Health and Human ServicesNational Institutes of HealthNational Heart, Lung and Blood Institute, 2003

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Stroke Pathways & Order SetsUse of Stroke pathways and order sets in theED and at admission aid in:1. Following specific guidelines for stroke

care in relation to hypertension control, cardiac monitoring and other parameters

2. Use of appropriate diagnostics for workup3. Streamline the process to avoid delays in t-

PA administration4. Simplify order entry and accuracy

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CEA: Secondary Prevention In pts with 70-99% carotid stenosis that is symptomatic

(specifically defined as having contributed to a TIA or minor stroke), CEA significantly reduces the 2y risk for stroke from 26% to 9%

For pts with 50-70% stenosis, the risk for stroke over 5 years decreases from 22% to 16% with surgery benefit is seen mostly in men, in those with recent stroke

symptoms, and in those with hemispheric compared with ocular symptoms

CEA is most beneficial when performed within the first 2-4 wks after the initial cerebrovascular event

Surgical risk for perioperative stroke or death must be <6% for this benefit in symptomatic carotid stenosis

no benefit for stenosis <50%.

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Available Emergency Department (ED) tools that utilize AHA guidelinesED Ischemic Stroke PathwayED Hemorrhagic Stroke (ICH/SAH)

PathwayED Transient Ischemic Attack Pathway

(TIA)The pathways are posted in trauma and CT rooms and work stations

ED Stroke Order Set

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ED PathwaysED Pathways

Can be accessed on MMC intranet Stroke Service Program

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Can be accessed on MMC intranet Stroke Service Program

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Admission Order SetsAdmission Order SetsStroke Ischemic AdultStroke Post ThrombolysisStroke-Hemorrhagic ICH / SAHStroke mini–Order (add on to other

admission order sets)TIAThese order sets incorporate AHA guidelines and quality measures, thus use is strongly encouraged to assist in the decision making process yet allowing for provider judgment. Use of order sets improves quality outcomes and streamlines the admission orders process.

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Access to order sets for stroke:

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Example of Order Set:

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Joint Commission Quality Measures(all are being monitored for compliance)

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Stroke Patient Placement:Stroke Patient Placement:Patient placement is planned with use of

designated stroke unit beds unless other factors determine otherwise

Treatment in a stroke unit has been shown to reduce death, dependence and need for long term institutional care in comparison to a general unit

Care is multidisciplinary

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Available resources to provide Evidence-based Care

American Heart Association (AHA) Statements and Practice Guidelines for TIA, Ischemic and Hemorrhagic stroke, Atrial fibrillation

These can be found on the MMC intranet in Department section under Stroke Service Program

https://my.mmc.org/C19/C5/American%20Stroke%20Association%20Ed/default.aspxhttps://my.mmc.org/C0/C6/Maine%20Medical%20Center%20-%20In%20Hous/default.aspx

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Intranet access:Intranet access:

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Maine Medical Center Stroke Program - Operations Group

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Stroke Service Contacts:Stroke Service Contacts: Medical Director: John Belden, MD

207-883-1414 Extension 361 jbelden@maineneurology.com

Nurse Practitioner: Georgann Dickey, RN, ANP 207-662-2069 dickeg1@mmc.org

Program Manager: Darcy Evans BA, BS 207-662-3406 evansd1@mmc.org

We encourage input to improve stroke practice and the tools used to facilitate care.

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Intranet Stroke Education Resources: E-learns MMC library including E-books, clinical

resources and research assistance Stroke Self-study for residents:

http://www.umassmed.edu/strokestop PowerPoint presentations: Medical Grand Rounds: Stroke Dysphagia Intracranial Hemorrhage Stroke Secondary Prevention

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Post-test question(s):1. Patient inclusion criteria for fibrinolytic therapy for

acute ischemic stroke include age 18 or older, onset of symptoms less than 180 minutes before treatment would start, and

a) Stroke within previous monthb) INR< 1.7c) Serum glucose > 400 d) Blood pressure >210/120

Ans. b

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Post-test question(s):2. Which ONE of the following factors puts a 40 year

old man at the GREATEST risk of having a stroke?

a) Blood pressure of 160/95 on repeated measurementb) Body mass index of 28c) Consumption of 1 or 2 cans of beer after dinner most

nightsd) Prior history of cigarette smoking while a teenager

Ans. a

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Post-test question(s):3. To reduce the risk of pneumonia in Mrs. WO, a

stroke patient who has facial droop and dysarthria, the following is recommended:

a) Keep her N.P.O. until a swallowing evaluation has been completed by either physician or speech therapy

b) Order elevation of the head of her bed 20 degrees when providing feeding assistance

c) Discourage performing mouth care as this can make her gag

d) Recommend keeping her supine to decrease episodes of coughing 

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Post-test question(s):4. The Stroke service program at MMC encourages

which of the following to promote optimal stroke care?

a) Use of specific stroke order setsb) Requesting smoking cessation counseling and/or

medications for tobacco usersc) Consider rehabilitation for all stroke patientsd) All of the above

Ans. d

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