Project: Ghana Emergency Medicine Collaborative
Document Title: Stroke Management in the 21st Century: What Do You
Need to...
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GEMC - Stroke Management in the 21st century: What Do You Need To Know? - Resident Training

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This is a lecture by Dr. Rashmi Kothari from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC - Stroke Management in the 21st century: What Do You Need To Know? - Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Stroke Management in the 21st Century: What Do You Need to Know? Author(s): Rashmi Kothari (Michigan State University), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. 2 To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. !"#$%&$'($)*+($*,&-.$/.+&0(1$ •  2"3+%$4(*%356$)*-/($&7$%(*."$ •  8(*%356$)*-/($&7$*%-4.$%3/*,343.#$ •  9:;<:=$>&+.*43.#$ 3
  4. 4. ?3%%4($@(+(,+*4$A57*+)B&5$ Source unknown Source unknown 4
  5. 5. 23//-(;C4*/>35&6(5$D)BE*.&+$35$ D)-.($A/)"(>3)$F.+&0($ •  •  •  •  •  G&-,4(;,435%(%$ C4*)(,&$)&5.+&44(%$ :HI>6J06$ K9L$M*B(5./$ 2+(*.(%$'3."35$<$"&-+/$ –  NJ9$'3."35$I:$>35-.(/$ –  NJ9$'3."35$IN;NO:$>35-.(/$ •  L$P-.)&>($>(*/-+(/$ Reference: Tissue Plasminogen Activator for Acute Ischemic Stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group5 N Engl J Med 1995; 333:1581-1588. http://www.nejm.org/doi/full/10.1056/NEJM199512143332401.
  6. 6. QAQGF$+.;CD$F.+&0($2+3*4$R(/-4./$ •  <:=$>&+($430(4#$.&$"*E($7*E&+*,4($<;>&5."$&-.)&>($ –  !"#$SNH9;9HITUP%%/$R*B&$S:;I:$>35-.(/T$ $$ –  !"$$SNH<;9HITUP%%/$R*B&$SIN;NO:T$$>35-.(/T$ $$ •  F3653V)*5.4#$"36"(+$35.+*)(+(,+*4$"(>&++"*6($+*.($ –  %"&=$C4*)(,&$ –  &"'=$+.;CD$ •  Q&$%3W(+(5)($35$>&+.*43.#$ –  (!=$C4*)(,&$ –  !$=$+.;CD$ 6
  7. 7. 23>($.&$2+(*.>(5.$ •  )*+,-*U$$$$."(+*M(-B)$ $ $$$$$$$$$$'35%&'$ •  ."$*+,-*U$>(%3*5$B>($.&$ $$$$$$$$$$XG$*++3E*4$ •  )"&/*U$$$$=$.+(*.(%$35$ $ $$$$$$$$$$QAQGF$SK9L$&7$ $$$$$$$$$$ NYZ<9LT$ Retro00064. Wikimedia Commons 7
  8. 8. Jmkim dot com, Wikimedia Commons 8
  9. 9. F.+&0($@"*35$&7$F-+E3E*4$[$R()&E(+#$ •  •  •  •  •  •  •  G(.()B&5$X*+4#$R()&653B&5$ G3/M*.)"$X*+4#$X?F$D)BE*B&5$ G(43E(+#$2+*5/M&+.$[$?*5*6(>(5.$ G&&+$XG$2+3*6($ G*.*$XG$XE*4-*B&5$[$?*5*6(>(5.$ G()3/3&5$FM()3V)$2"(+*M3(/$ G+-6$2"+&>,&4#B)$[$Q(-+&M+&.()BE($2"(+*M#$ 9
  10. 10. G(.()B&5$ •  !"*.$*+($F365/$[$F#>M.&>/1$ –  L<=$6(5(+*4$M-,43)$%3%5 .$05&'$*5#$ –  <I=$&7$*)-.($/.+&0($M*B(5./$%3%5 .$05&'$*5#$ •  !"*.$*+($R3/0$]*).&+/1$ –  <9=$6(5(+*4$M-,43)$%3%5 .$05&'$*5#$ –  L<=$&7$*)-.($/.+&0($M*B(5./$%3%5 .$05&'$*5#$ Pancioli JAMA 1998;279 Kothari Stroke 1997;28 10
  11. 11. !"*.$%&$#&-$5((%$.&$05&'$*,&-.$/.+&0(1$ •  F365/$[$F#>M.&>/$ –  &5(;/3%(%$(^.+(>3.#$ '(*05(//$ –  &5(;/3%(%$5->,5(//$ –  %3_)-4.#$/M(*0356$ –  E3/-*4$M+&,4(>/$ •  R3/0$]*).&+/$ –  "#M(+.(5/3&5$ –  %3*,(.(/$>(443.-/$ –  />&0356$ –  "(*+.$%3/(*/($ –  M+3&+$/.+&0(/$ –  &4%(+$*6($ –  +*)($SD7+3)*5;D>(+3)*5/T$ 11
  12. 12. @35)355*B$C+("&/M3.*4$F.+&0($F)*4($ Shantoo, Wikimedia Commons Facial Droop Normal: Abnormal: Gonad, Wikimedia Commons Normal: Abnormal: St Bartholomew's Hospital Archives & Museum, Wellcome Images Normal: Abnormal: Both sides of face move equally One side of face does not move at all Arm Drift Both arms move equally or not at all One arm drifts compared to the other Speech Patients use correct words with no slurring Slurred or inappropriate words or mute 12
  13. 13. G3/M*.)"$@*44$INN$ Mark Wolfe, Wikimedia Commons 13
  14. 14. `(5(+*4$C-,43)/ $C(+)(MB&5$&7$!"*.$.&$%&$35$ @*/($&7$*$F.+&0($ •  I:=$'&-4%$/((0$>(%3)*4$*a(5B&5$ –  L<=$)*44$INN$3>>(%3*.(4#$ –  9K=$)*44$."(3+$7*>34#$%&).&+$ –  NN=$6&$/.+*36".$.&$."($XG$ NSA/Gallop Poll 1996 14
  15. 15. Onset to ED Arrival (hours) A53B*4$?(%3)*4$@&5.*).$E(+/-/$23>($&7$XG$ D++3E*4$ 7 6 5 4 3 2 1 0 Barsan Arch Intern Med. 1993 6.3 5.6 4.5 3.5 2.6 Mean Median 1.4 911 Private MD ED 15
  16. 16. G(43E(+#$2+*5/M&+.$[$?*5*6(>(5.$ •  •  •  •  •  •  •  EyOne, Wikimedia Commons Db@/$ F.+&0($+()&653B&5$ 23>($&7$&5/(.$ Q(-+&4&63)*4$(E*4-*B&5$ @"()0$64-)&/($ X*+4#$"&/M3.*4$5&BV)*B&5$ R*M3%$2+*5/M&+.cccccc$ 16
  17. 17. X>(+6(5)#$G(M*+.>(5.$?*5*6(>(5.$ •  •  •  •  G&&+$XG$2+3*6($ G*.*$XG$XE*4-*B&5$$ G()3/3&5$FM()3V)$2"(+*M3(/$ G+-6$2"+&>,&4#B)$2"(+*M#$ 17 Russell Lee, Wikimedia Commons
  18. 18. Shantoo, Wikimedia Commons 2+3*6($ 18
  19. 19. G*.*$ Photographer's Mate 1st Class Michael R. McCormick, Wikimedia Commons 19
  20. 20. G()3/3&5$ S!"&$F"&-4%$A$2+(*.1T$ •  A5)4-/3&5$@+3.(+3*$ •  X^)4-/3&5$@+3.(+3*$ 20
  21. 21. $A5)4-/3&5$@+3.(+3*$ •  @4353)*4$C+(/(5.*B&5$&7$A/)"(>3)$F.+&0($ •  P5/(.$'3."35$<$"&-+/$ 21
  22. 22. X^)4-/3&5$@+3.(+3*$ •  •  •  •  •  •  •  •  01-23*4)*+56,-* 784!9.:!!%* d(>&++"*6($&5$@2$ ;2<=6,2*>3*51-23$ F-+6(+#$NL$%*#/$ 2+*->*$<$>&5."/$ F.+&0($$<$>&5."/$ ?353>*4$&+$+(/&4E356$ /#>M.&>/$ •  •  •  •  •  •  •  `AJ`e$,4((%$9N$%*#/$ C+3&+$A@d$&+$FDd$ ?2@213*AB* P5$@&->*%35$C2fNHg$ 01*+2C>,<1*8DD4(!$ C4*.(4(./$hN::Z:::$ EF6@5-2*4'%%$ 22
  23. 23. G+-6$ Sd&'$G&$i&-$2+(*.1T$ •  C+(;2+(*.>(5.$ –  64-)&/(Z$QAdFFZ$@2Z$@&5/(5.$ •  G&/356$ •  ?&53.&+356$ 23
  24. 24. G&/356$ •  :HI$>6J06$S>*^HUI:$>6T$ •  N:=$,&4-/$S&E(+$N$ >35-.(T$ •  N$"&-+$357-/3&5$ Mass Communication Specialist Seaman Andrew Skipworth, Wikimedia Commons 24
  25. 25. C*B(5.$?&53.&+356$ •  A@e$*%>3//3&5$S9L$"&-+/T$ •  Q(-+&$)"()0/$$ –  j$Ng$>35-.($k$K$"&-+/$ –  j$N$"&-+$k$NO$"&-+/$ •  bC$)"()0/$$ 25
  26. 26. b4&&%$C+(//-+($?*5*6(>(5.$ •  Q&5;2"+&>,&4#B)$@*5%3%*.(/$ •  2"+&>,&4#B)$@*5%3%*.(/$ –  M+(;.+(*.>(5.$SNOgJNN:$>>d6T$ –  %-+356$[$M&/.;.+(*.>(5.$ 26
  27. 27. bC$?*5*6(>(5.$ •  Q&5;2"+&>,&4#B)$@*5%3%*.($ –  G&5 .$2+(*.ccc$ •  C+(;2"+&>,&4#/3/$ –  b($`(5.4(ccc$ •  G-+356$[$C&/.;2"+&>,&4#/3/$ –  b($D66+(//3E(ccc$ 27
  28. 28. QAQGF;R()&>>(5%(%$2*+6(./$ •  •  •  •  G&&+;.&;%&).&+ $ $ $N:$>35-.(/$ G&&+;.&;@2$ $ $ $$$$$$9g$>35-.(/$ G&&+;.&;@2$+(*%356 $$$$$$Lg$>35-.(/$ G&&+;.&;.+(*.>(5. $ $K:$>35-.(/$ 28
  29. 29. F.+&0($@"*35$&7$F-+E3E*4$[$R()&E(+#$ •  •  •  •  •  •  •  G(.()B&5$X*+4#$R()&653B&5$ G3/M*.)"$X*+4#$X?F$D)BE*B&5$ G(43E(+#$2+*5/M&+.$[$?*5*6(>(5.$ G&&+$XG$2+3*6($ G*.*$XG$XE*4-*B&5$[$?*5*6(>(5.$ G()3/3&5$FM()3V)$2"(+*M3(/$ G+-6$2"+&>,&4#B)$[$Q(-+&M+&.()BE($2"(+*M#$ 29
  30. 30. <;?&5."$]*E&+*,4($P-.)&>($ 20 Placebo rt-PA 31 0 10 20 30 Number of Patients ((N Engl J Med 1995:333) 40 30
  31. 31. A@d$G(*."/$*5%$?&+.*43.#$ Placebo 0.3 21 ICH Deaths Mortality rt-PA 3 0 17 5 10 15 20 25 Number of Patients (N Engl J Med 1995:333) 31
  32. 32. b*/(435($QAdFF$*5%$A@d$35$."($QAQGF$2+3*4$ Percentage of t-PA Patients with Symptomatic ICH 18 16 14 12 10 8 6 4 2 0 17 2 0-5 3 6-10 5 4 11-15 16-20 >20 Baseline NIH Stroke Scale Score (Broderick, Stroke 1997) 32
  33. 33. G3/M&/3B&5$R(/-4./$7+&>$QAQGF$2+3*4$ LOS rt-PA Placebo n=312 n=312 p Value 10.88+10.04 12.41+11.10 0.02 (mean days +SD) Disposition 0.002* Home 151 (48%) 112(36%) Rehab unit 91 (29%) 115 (37%) Nursing home 22 (7%) 39 (13%) Dead 35 (11%) 40 (13%) Other 13 (4%) 6 (2%) Neurology 1998;50 * compared home to all other dispositions 33
  34. 34. X^.(5%356$."($2"(+*M(-B)$!35%&'$ ! ! )*'&+$,! !"#$ ))?! @4A?B! CD4E?! ))?! C4C?B! @4E?! !"#$ )@?! GD?B! CH?B! GE?! A?B! C)?B! !"#$ ID4)?! H4H?B! CD4J?! %&'()*+$ §% 12'34! %&'()*+$ F/:>>!..! 5&6$789$2! %&'()*+$ F/:>>! ./0! )*'&+$,-! :;<:=;.>! "#$%&'(! )@4@?! )4I?B! CD4A?! mRankin 0-1 for ECASS I & II, NIHSS<1 for ALANTIS at 3-months 34
  35. 35. R*5%&>3l(%$F.+(M.&035*/($2+3*4/$ Study Time to Treat 228 <4 hrs MAST-I 622 <6 hrs Mortality SK+ASA NA 43% NA 22% SK 18% 35% Placebo MAST-E 270 <6 hrs Treatment ICH ASA ASK N 3% 18% SK+ASA 10% 34% SK 6% 19% ASA 2% 10% Placebo 0.6% 13% 35

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