STROKE
TELEMEDICINE
Ryan Heyborne, MD
Idaho Emergency Physicians – June 2009
“Telemedicine can be an
effective method to provide
expert stroke care to patients
located in rural areas.”
- 2007 AHA/ASA...
Stroke Telemedicine
 Stroke Centers limited in Idaho
 Time critical
 Many facilities not comfortable with diagnosis
and...
Stroke Telemedicine (cont)
 Stroke Telemedicine. Mayo Clin Proc. 2009;84
 ~20 telestroke networks worldwide – CA, NY, GA...
Primary Stroke Center
~200
Hospital
s in US
Overview
 Tools to provide direction
 Not meant to be an esoteric lecture
 TIA’s
 Stroke Protocol
 Thrombolytics
 In...
TIA’s
 TIA defined
 AHA: “A TIA is a "warning stroke" or "mini-stroke"
that produces stroke-like symptoms but no
lasting...
TIA Workup
 Predictor of Stroke
 Angina of the Brain
 Risk Stratification
 Inpatient v. Outpatient
 Risk Factor Based...
ABCD2
 A (Age); 1 point for age >60 years,
 B (Blood pressure > 140/90 mmHg); 1 point for
hypertension at the acute eval...
ABCD2 (cont)
 ABCD2 Score
 Guideline only – Clinical Judgment Trumps
 Validated in Multiple Studies – “Best” for ED Use...
TIA Workup
 Cardiac Monitoring, EKG
 Head CT
 Physical Examination
 Labs, Consider Hypercoag.
 Carotid Duplex US
 Co...
Treatment
 AHA/ASA 2006 – Guidelines for Prevention of
Stroke in TIA/Ischemic Stroke
 Risk Factor Modification: DM/HTN/T...
TIA Summary
 Decision of inpatient v. outpatient
 Resource-based
 May need stroke center, may not
Stroke
Stroke Protocol
 Preparation
 Maintain patient safety (escort/fall precautions)
 Obtain VS, Pulse-ox
 Monitor, O2 @ 2L...
Stroke Protocol (cont)
 Assessment
 Respiratory Status – patent airway, secretions
 Neurological Status
 LOC
 Speech ...
NIH Stroke Scale
 Within 10 minutes
 Level of Consciousness
 Visual – Gaze/Fields
 Motor –
Facial/Extremities/Ataxia
...
Stroke Protocol (cont)
 Brain Attack Team
 Activate if symptoms < 3 hours
 Includes
 Emergency Physician
 Emergency N...
Stroke Protocol (cont)
 2 IV Sites
 Labs – Cardiac Panel,
Coags
 EKG
 CXR? (2007)
 Brain Attack Protocol
Head CT
 No...
Intervention
 IV t-PA
 IA t-PA
 Clot retrieval
 Admission
 ICU if Thrombolytics
 Telemetry if not
IV t-PA
 Studies
 NEJM 1995 – National Institute of Neurological
Disorders and Stroke (NINDS)
 Overall, for every 100 p...
Improved Outcomes
 Modified Rankin Score
 0 - No symptoms at all
 1 - No significant disability despite symptoms; able ...
IV t-PA continued
 From St. Al’s t-PA Information sheet:
 “1 out of 9 received benefit and 1 out of 16 had a
serious ble...
Sorting through the Criteria…
 Evolving
 Always at
your
fingertips
online.
 Clinical
judgment
and open
discussion
…
IV t-PA Inclusion Criteria
 Stroke onset less than 3 hours
 Age > 18
 Informed Consent
 Neurologic deficit measurable ...
IV t-PA Exclusion
 Evidence of intracranial hemorrhage, mass-efffect
or edema on noncontrast head CT, or history of
ICH
...
IV t-PA Exclusion (cont)
 SBP > 185 or DBP > 110 repeatedly or requiring
agrressive Tx to keep below
 Labetalol 10 mg re...
IV t-PA Exclusion (cont)
 Only minor (sensory loss, ataxia, dysarthria
alone) or rapidly improving stroke symptoms
 Pati...
IV t-PA Criteria (cont)
 Relative Contraindications
 Age > 80
 Pericarditis/Endocarditis
 Liver/Kydney Dysfunction
 D...
IV t-PA Criteria (cont)
 Summary of Indications/Contraindications
 Requires an open, in-depth discussion with the
patien...
Safe in a Telemedicine Setting
Telemedicine for Safe and Extended Use of
Thrombolysis in Stroke: The Telemedic Pilot
Proje...
Giving IV t-PA
 “Alteplase”
 0.9 mg /kg up to 90 mg
 10% as a bolus and the rest to be infused over
one hour.
 Start a...
Giving t-PA (cont)
 Q 15 min. BP measurements
 No Heparin, aspirin, clopidogrel, etc. for 24
hours
 Standard treatments...
Post t-PA Blood Pressure
Mgmt.
 2007 AHA/ASA Stroke Guidelines
 Measure Q 15 minutes
 Don’t treat below ~180/105
 Syst...
t-PA Reversal
 Intracranial Hemorrhage
 Acute neurologic deterioration, new headache, BP
spike, nausea/vomiting
 Stop t...
t-PA Summary
 Risk/Benefit Discussion
 Blood pressure management to 180/110
 Labatelol first line
 0.9 mg /kg up to 90...
Intra Arterial Thrombolytics
 Interventional Radiology Direct Injection
 Similar Exclusion Criteria
 Dissection/Stenosi...
IA Thrombolytics (cont)
 Results
 Positive
 Treatment group – 40% Rankin score of 2 or less
 Control group – 25% Ranki...
IA Thrombolytics Summary
 IA t-PA considered equivalent to r-proUK
 Consider if < 6 hours and lesion amenable on
CTA
 D...
Mechanical Retreival
 MERCI Retriever
(Mechanical Embolus
Removal in Cerebral
Ischemia)
 Consideration up to 6-8
hours
...
Mechanical (cont)
 Inclusion
 Acute large vessel stroke
 NIHSS ≥ 8
 8 hours of symptom onset for MERCI and
Penumbra de...
Summary
 TIA
 Risk Factor Stratification
 Risk management
 Stroke
 Time sensitive treatments
 St. Al’s is Stroke Cen...
Summary (cont)
 Stroke Treatments
 IV Thrombolytics
 Symptoms less than 3 hours
 Careful discussion of indications/con...
Discussion / Questions
Stroke telemedicine Ryan Heyborne, MD
Stroke telemedicine Ryan Heyborne, MD
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Stroke telemedicine Ryan Heyborne, MD

  1. 1. STROKE TELEMEDICINE Ryan Heyborne, MD Idaho Emergency Physicians – June 2009
  2. 2. “Telemedicine can be an effective method to provide expert stroke care to patients located in rural areas.” - 2007 AHA/ASA Stroke Guidelines
  3. 3. Stroke Telemedicine  Stroke Centers limited in Idaho  Time critical  Many facilities not comfortable with diagnosis and/or treatment without support  Visual diagnosis helpful  Guidance in treatment  Thrombolytics
  4. 4. Stroke Telemedicine (cont)  Stroke Telemedicine. Mayo Clin Proc. 2009;84  ~20 telestroke networks worldwide – CA, NY, GA, AZ, MI, MA, MD, TX, PA, UT, NV, CO, Canada, Europe  Hub and spoke hospitals  Communication established within 40 min of arrival (initial assessment begun and tests ordered)  Treatments recommended and started within 60 min.
  5. 5. Primary Stroke Center ~200 Hospital s in US
  6. 6. Overview  Tools to provide direction  Not meant to be an esoteric lecture  TIA’s  Stroke Protocol  Thrombolytics  Interventional Radiology
  7. 7. TIA’s  TIA defined  AHA: “A TIA is a "warning stroke" or "mini-stroke" that produces stroke-like symptoms but no lasting damage.”  Some controversy regarding “duration”  Most < 30 min.  Many over 60 min. (never more than 24 h)  Practical purposes – only having this discussion if already resolved. Kimura K. The duration of symptoms in transient ischemic attack. Neurology 1999
  8. 8. TIA Workup  Predictor of Stroke  Angina of the Brain  Risk Stratification  Inpatient v. Outpatient  Risk Factor Based – ABCD2  Resource Based – Many hospitals can’t do workup
  9. 9. ABCD2  A (Age); 1 point for age >60 years,  B (Blood pressure > 140/90 mmHg); 1 point for hypertension at the acute evaluation,  C (Clinical features); 2 points for unilateral weakness, 1 for speech disturbance without weakness, and  D (symptom Duration); 1 point for 10–59 minutes, 2 points for >60 minutes.  D (Diabetes); 1 point
  10. 10. ABCD2 (cont)  ABCD2 Score  Guideline only – Clinical Judgment Trumps  Validated in Multiple Studies – “Best” for ED Use  Recent Study – Neurology; June 2009 (half in first 24 h)  Stroke risk at 2 days, 7 days, 30 days, and 90 days:  Scores 0-3: low risk (1-4%)  Scores 4-5: moderate risk (4-14%)  Scores 6-7: high risk (8-23%)  Admit Moderate/High risk – Low risk MAY be worked up as outpatient and started on antiplatelet therapy.Johnston SC. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007.
  11. 11. TIA Workup  Cardiac Monitoring, EKG  Head CT  Physical Examination  Labs, Consider Hypercoag.  Carotid Duplex US  Consider MRI/MRA  Consider Echocardiogram
  12. 12. Treatment  AHA/ASA 2006 – Guidelines for Prevention of Stroke in TIA/Ischemic Stroke  Risk Factor Modification: DM/HTN/Tob/etc.  Non-cardiogenic ischemic stroke or TIA:  Aspirin Alone – Low dose (81-325 mg/day) adequate  Aspirin and Dipyridamole  Plavix Alone – increased bleeding risk with Aspirin and Plavix  Cardiogenic – arrhythmia, vascular disease, PFO  Consider Coumadin, referral for cardiology intervention
  13. 13. TIA Summary  Decision of inpatient v. outpatient  Resource-based  May need stroke center, may not
  14. 14. Stroke
  15. 15. Stroke Protocol  Preparation  Maintain patient safety (escort/fall precautions)  Obtain VS, Pulse-ox  Monitor, O2 @ 2L (Sat 95%)  History  Event History – Time of Onset, affected function  PMH – Recent Trauma or Procedures
  16. 16. Stroke Protocol (cont)  Assessment  Respiratory Status – patent airway, secretions  Neurological Status  LOC  Speech Clarity and Pattern  Facial Symmetry  Hand Grip, foot push/pull  Paresthesia/Paralysis  Blood Glucose Check
  17. 17. NIH Stroke Scale  Within 10 minutes  Level of Consciousness  Visual – Gaze/Fields  Motor – Facial/Extremities/Ataxia  Sensory – Pinprick  Speech  Neglect http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf
  18. 18. Stroke Protocol (cont)  Brain Attack Team  Activate if symptoms < 3 hours  Includes  Emergency Physician  Emergency Nurse  Phlebotomist  CT Tech  ED Tech  Brain Attack Radiologist  Stroke Service  The telemedicine Emergency Physician
  19. 19. Stroke Protocol (cont)  2 IV Sites  Labs – Cardiac Panel, Coags  EKG  CXR? (2007)  Brain Attack Protocol Head CT  Noncontrast Head CT  CT angiogram of carotid artery and Circle of Willis
  20. 20. Intervention  IV t-PA  IA t-PA  Clot retrieval  Admission  ICU if Thrombolytics  Telemetry if not
  21. 21. IV t-PA  Studies  NEJM 1995 – National Institute of Neurological Disorders and Stroke (NINDS)  Overall, for every 100 patients treated within the first 3 hours, 32 had a better outcome as a result and 3 a worse outcome.  Lancet 2004 – Pooled analysis of multiple studies (ATLANTIS, ECASS, NINDS)  2775 Patients  Favorable 3-month outcome  Multiple measures – common - Modified Rankin Scale: Shifting a grade compared to placebo  Odds Ratio 2.81 if < 90 min.  Odds Ratio 1.55 90-180 min.  Odds Ratio 1.40 180-270 min.
  22. 22. Improved Outcomes  Modified Rankin Score  0 - No symptoms at all  1 - No significant disability despite symptoms; able to carry out all usual duties and activities  2 - Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance  3 - Moderate disability; requiring some help, but able to walk without assistance  4 - Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance  5 - Severe disability; bedridden, incontinent and requiring constant nursing care and attention  6 - Dead
  23. 23. IV t-PA continued  From St. Al’s t-PA Information sheet:  “1 out of 9 received benefit and 1 out of 16 had a serious bleeding complication…”  ECASS 3 (NEJM 2008) - consider out to 4.5 hours – need more data, may consider in some cases – discuss with neurologist.  Risk of Hemorrhage increases from 1.1% to 5.9% with no significant difference in mortality rate  Not FDA Approved – Recommended by ASA with qualifications  Stroke Scale < 25, age <80, anticoagulation, H/O CVA and DM
  24. 24. Sorting through the Criteria…  Evolving  Always at your fingertips online.  Clinical judgment and open discussion …
  25. 25. IV t-PA Inclusion Criteria  Stroke onset less than 3 hours  Age > 18  Informed Consent  Neurologic deficit measurable on NIH stroke scale  No specific cut off (around 5 to 22)  CT scan of the brain showing no evidence of intracranial hemorrhage  Labs Reviewed
  26. 26. IV t-PA Exclusion  Evidence of intracranial hemorrhage, mass-efffect or edema on noncontrast head CT, or history of ICH  High suspicion of subarachnoid hemorrhage (if CT nl)  History of intracranial neoplasm, arteriovenous malformation, or aneurysm  Active internal bleeding (e.g., GI or urinary bleed- 21d)  Asymptomatic, non-anemic guiac + not absolute contraindication  Within 3 months of previous stroke, intracranial surgery, serious head trauma  Recent acute myocardial infarction (around a
  27. 27. IV t-PA Exclusion (cont)  SBP > 185 or DBP > 110 repeatedly or requiring agrressive Tx to keep below  Labetalol 10 mg repeated x 1 OR  Nitropaste 1-2” OR  Nicardipine infusion 5-15 mg/hr  Major Surgery within 14 days  Known bleeding diathesis such as (not limited to)  Platelet count <100,000/mm  Heparin/Lovenox within 48 hours and had an elevated pTT  Recent use (48 h) of anticoagulant (e.g., warfarin sodium) and elevated PT (INR > 1.5)  Glucose is <50 mg/dL or >400  Witnessed seizure at stroke onset
  28. 28. IV t-PA Exclusion (cont)  Only minor (sensory loss, ataxia, dysarthria alone) or rapidly improving stroke symptoms  Patient has a large stroke/MCA Infarct  In consultation with Neurologist  NIHSS 22-25 or more  Recent arterial puncture at non-compressible site  Severe complicated condition that may confound treatment (Neuro, Psych, Cancer, AIDS, etc)  Pregnant
  29. 29. IV t-PA Criteria (cont)  Relative Contraindications  Age > 80  Pericarditis/Endocarditis  Liver/Kydney Dysfunction  Diabetic Hemorrhagic Retinopathy  Occluded/Infected AV cannula (hemodialysis)  Lumbar puncture within 7 days  Within 14 days of serious trauma
  30. 30. IV t-PA Criteria (cont)  Summary of Indications/Contraindications  Requires an open, in-depth discussion with the patient and family members  IF you’re going to do it, do it right…  ED “Stroke Packet”  ED orders  Thrombolytic Checklist for stroke / Order Sheet  Risk and benefits information sheet  Admission Order Sheet  So you don’t have to commit it all to memory…  All available on telemedicine web-site
  31. 31. Safe in a Telemedicine Setting Telemedicine for Safe and Extended Use of Thrombolysis in Stroke: The Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria Stroke 2005;36;287-291 “The present data suggest that systemic thrombolysis indicated via stroke experts in the setting of teleconsultation exhibits similar complication rates to those reported in the NINDS and Stroke trial. Therefore, tPA treatment is also safe in this context and can be extended to nonurban areas.”
  32. 32. Giving IV t-PA  “Alteplase”  0.9 mg /kg up to 90 mg  10% as a bolus and the rest to be infused over one hour.  Start at Outside Facility  During Transport  Need Paramedic  Lifeflight
  33. 33. Giving t-PA (cont)  Q 15 min. BP measurements  No Heparin, aspirin, clopidogrel, etc. for 24 hours  Standard treatments if having seizure but prophylaxis not routinely given  ICU monitoring  Monitor for Bleeding
  34. 34. Post t-PA Blood Pressure Mgmt.  2007 AHA/ASA Stroke Guidelines  Measure Q 15 minutes  Don’t treat below ~180/105  Systolic 180-230; Diastolic 105-120  Labetalol – boluses to max of 300 mg v. infusion 2-8 mg/hr  Systolic >230; Diastolic >120  Labetalol as above  Nicardipine 5-15 mg/hr (titrate by 2.5 every 5 minutes)  Consider nitroprusside
  35. 35. t-PA Reversal  Intracranial Hemorrhage  Acute neurologic deterioration, new headache, BP spike, nausea/vomiting  Stop t-PA infusion  Stat Head CT  Stat Pt, PTT, fibrinogen, Platelet count  Prepare for administration of  6-8 units of cryoprecipitated fibrinogen  Platelets  Factor VII  Neurosurgical consultation  Don’t need to have this all available to start infusion
  36. 36. t-PA Summary  Risk/Benefit Discussion  Blood pressure management to 180/110  Labatelol first line  0.9 mg /kg up to 90 mg  ICU Admission  Follow closely for deterioration
  37. 37. Intra Arterial Thrombolytics  Interventional Radiology Direct Injection  Similar Exclusion Criteria  Dissection/Stenosis/Poor Visualization  PROACT II (JAMA 1999)  Acute strokes less than 6 hours duration caused by middle cerebral artery occlusion.  180 patients in 54 centers  Patients given 9 mg of IA r-proUK PLUS IV heparin VS IV heparin alone
  38. 38. IA Thrombolytics (cont)  Results  Positive  Treatment group – 40% Rankin score of 2 or less  Control group – 25% Rankin score of 2 or less  Negative  Increase in intracranial hemorrhage with neurologic deterioration within 24 hours  10% of IA r-proUK vs 2% of control  Overall mortality at 90 days was 25% for IA r- proUK vs 27% of control
  39. 39. IA Thrombolytics Summary  IA t-PA considered equivalent to r-proUK  Consider if < 6 hours and lesion amenable on CTA  Decision in consultation with Neuroradiologist/ Neurologist
  40. 40. Mechanical Retreival  MERCI Retriever (Mechanical Embolus Removal in Cerebral Ischemia)  Consideration up to 6-8 hours  Can be safely combined with IV-tPA – Am J Neuroradiol 2006
  41. 41. Mechanical (cont)  Inclusion  Acute large vessel stroke  NIHSS ≥ 8  8 hours of symptom onset for MERCI and Penumbra devices  6 hours of symptom onset for IA tPA  Exclusions  Significant cytotoxic edema  Blood on Head CT  Allow consideration of the post trauma, post partum, and post surgical patient.
  42. 42. Summary  TIA  Risk Factor Stratification  Risk management  Stroke  Time sensitive treatments  St. Al’s is Stroke Center  NIH Stroke Scale  Appropriate Initial Work-up/Evaluation prior to transfer/Stroke Team Activation
  43. 43. Summary (cont)  Stroke Treatments  IV Thrombolytics  Symptoms less than 3 hours  Careful discussion of indications/contraindications  IA Thrombolytics  Symptoms less than 6 hours with favorable lesion  Mechanical Retreival  Symptoms less than 8 hours with favorable lesion
  44. 44. Discussion / Questions

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