Project: Ghana Emergency Medicine Collaborative
Document Title: The Management of Acute Ischemic Stroke & TIA
Author(s): R...
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The Management of Acute
Ischemic Stroke & TIA
Rashmi U. Kothari, M.D.
Borgess Research Institute
Department of Emergency M...
65 y.o. Fire Chief w/ Lt arm
numbness & weakness X 15 minutes
Has 15 minutes of
symptoms now normal
  Wife takes him to E...
70 y.o male “found down” while
cutting lawn
  Last

seen 1hr to 911
  Rt arm/leg weakness
  Hx of HTN, DM,
resolved old...
41y.o male w/ Lt eye deviation &
drooling. RN notes initial BP= 200/110
  Brought

to ED 5 hrs.
after onset
  Lt. Eye de...
The Management of Acute
Ischemic Stroke & TIA
Rashmi U. Kothari, M.D.
Borgess Research Institute
Department of Emergency M...
Stroke Chain of Survival & Recovery

Elsie esq., flickr

Detection

Seattle Municipal Archive,
Wikimedia Commons

Dispatch...
Goals
  Stroke

definitions
  Management of TIA
  Management of Ischemic Stroke
– management of hyper-acute stroke

9
Definition of Stroke
Any disease process that decreases
vascular blood flow to a certain region
of the brain causing neuro...
Stroke Subtypes
Ischemic
85%

Thrombotic

Hemorrhagic
15%

Embolic
Sources of images undetermined

Intracerebral
Hemorrhag...
Stroke Vocabulary
 TIA

:
 Lacunar:
 “Mini-Strokes”:

Symptoms <24 hrs
Small infarcts
TIA

12
Current Management of TIA

Source undetermined

U.S. Navy, Wikimedia Commons

Mvhayes,
Wikimedia Commons
Novic84, Wikimedi...
Current Management of TIA
All new onset TIAs
should be admitted!!!

14
Short-term Prognosis after
ED Diagnosis of TIA
  Cohort

study
  1707 patients w/ TIAs
  Followed for 90 days
  3/97-2...
Independent Risk Factor of Stroke
within 90-days of a TIA
Odds Ratio

P value

Age>60

1.8

.01

Diabetes

2.0

<.001

>10...
90-day Stroke Risk by
Number of Risk Factors
# Risks
Factors

Patients
N=

Stroke w/in
90 days

0

22

0%

1

179

3%

2

...
Medical Interventions
in Patients with TIAs
Atrial fibrillation

Warfarin, Aspirin

Heparin,
Carotid stenosis
Endarterecto...
Exceptions to the Rule
  PMH of Stroke/TIA
–  Negative ED CT
–  recent negative stroke w/u
–  Close Follow-up
  Minimal ...
Current Management of TIA
All new onset TIA’s
should be admitted!!!

20
65 y.o. Fire Chief w/ Lt arm
numbness & weakness X 15 minutes
  Has

15 minutes of
symptoms now normal
  Wife takes him ...
Management of Ischemic Stroke
 Diagnostic

tests
 Anticoagulation
 BP management

Source undetermined

22
Diagnostic Tests
 Priority

studies
 Recommended studies
 Elective studies

23
Priority Studies
dextrostick

Source undetermined

Novic84, Wikimedia Commons

24
44 y.o male “found down”
while cutting lawn
  Last

seen 1hr to 911
  Rt arm/leg weakness
  Hx of HTN, DM, old
resolved...
Recommended Studies
 CBC

with platelets
 Basic Metabolic Panel
 PT & INR
 CXR
 U/A
26
Individualized Tests
 Cardiac
 VDRL

enzymes

 Antithrombin

III antibodies
 Protein C & S deficiency
 Antiphospholip...
Anticoagulation
and parsecs to go, flickr

  Heparin,

aspirin, ticlopidine, clopdiogrel,
dipyridamole, warfarin
  Commo...
Antiplatelet Agents
(aspirin, ticlopidine, clopdiogrel, dipyridamole)
 Long-term

reduction in stroke
 Long-term reducti...
Antiplatelet Agents
(aspirin, ticlopidine, dipyridamole, clopdiogrel*)

Event

Risk Reduction

Non-fatal Stroke

25%

Non-...
Heparin
 Commonly

used in acute setting
 No data supporting it’s use

31
International Stroke Trial (IST)
  467

Hospitals
  19,435 Patients

Heparin

  Factorial

Design

–  Heparin 5,000/12,...
International Stroke Trial: Results
Heparin

No Heparin

(N=9717)

(N=9718)

Events
preventable
per 1000

Ischemic Stroke
...
1989 Survey of Neurologist
Regarding Heparin Use
  82%

might decrease
recurrent emboli
  70% might be
indicated in
prog...
High Risk Stroke/TIA Patients
  Crescendo

TIAs
  Vertebrobasilar TIA
  High grade carotid stenosis
  Carotid / verter...
HEPARIN
36
Thrombolytic Candidates
 Can

treat patients who are on aspirin
 Avoid antiplatelet & anticoagulants X
24 hrs following ...
Blood Pressure Management
  Non-Thrombolytic

Candidates

  Thrombolytic

Candidates

– pre-treatment
Mvhayes,
Wikimedia...
Blood Pressure
Management In Stroke
  Guidelines

in old ACLS
(Advanced Cardiac Life
Support) Handbook
  In ACLS cards t...
BP Management for
Non-Thrombolytic Candidates
 Recheck

blood pressure
 DON’T TREAT acutely!

40
cc/min/gm

120/60 (MAP=80)

41
Source undetermined
Current Guidelines
 Recheck

BP

 Treat:

– Systolic BP >220-230
– Diastolic BP >120-130
 Reduce gradually
42
BP Management for
Thrombolytic Candidates
  Pre-Treatment

– Be gentle
» Systolic 185>
» Diastolic110>
  During/Post-Tx
...
BP Management
 Non-Thrombolytic

Candidate

– Don’t Treat!!!
 Pre-Thrombolysis
– Be Gentle!!!
 During & Post-Thrombolys...
41y.o male w/ Lt eye deviation &
drooling. RN notes initial BP= 200/110
  Brought

to ED 5 hrs.
after onset
  Lt. Eye de...
Key Points
 Admit

all new onset TIAs
 Avoid heparin use
 Treat only extreme HTN

46
70 y.o. female w/ Rt. sided weakness.
RN notes initial BP= 200/110
 Last

seen normal 5 hrs.

PTA
 Slurred speech, Rt ar...
Effectiveness of Heparin
In Progressive
 Phase

1:

– Late 1970’s
– 310 patients
– ↓speech/motor
between 2
exams
– No Hep...
41y.o male w/ Lt eye deviation &
drooling. RN notes initial BP= 200/110
  Brought

to ED 5 hrs.
after onset
  Lt. Eye de...
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GEMC: The Management of Acute Ischemic Stroke & TIA

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This is a lecture from the Ghana Emergency Medicine Collaborative (GEMC) 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.

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GEMC: The Management of Acute Ischemic Stroke & TIA

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: The Management of Acute Ischemic Stroke & TIA Author(s): Rashmi U. Kothari, M.D. (KCMS/MSU), 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. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. 2  
  3. 3. The Management of Acute Ischemic Stroke & TIA Rashmi U. Kothari, M.D. Borgess Research Institute Department of Emergency Medicine KCMS/MSU 3
  4. 4. 65 y.o. Fire Chief w/ Lt arm numbness & weakness X 15 minutes Has 15 minutes of symptoms now normal   Wife takes him to ED   Now refuses to be evaluated   Naval History and Heritage Command, flickr 4
  5. 5. 70 y.o male “found down” while cutting lawn   Last seen 1hr to 911   Rt arm/leg weakness   Hx of HTN, DM, resolved old stroke cduruk, flickr 5
  6. 6. 41y.o male w/ Lt eye deviation & drooling. RN notes initial BP= 200/110   Brought to ED 5 hrs. after onset   Lt. Eye deviation, drooling, slurred speech   RN notes elevated BP=200/110 6
  7. 7. The Management of Acute Ischemic Stroke & TIA Rashmi U. Kothari, M.D. Borgess Research Institute Department of Emergency Medicine KCMS/MSU 7
  8. 8. Stroke Chain of Survival & Recovery Elsie esq., flickr Detection Seattle Municipal Archive, Wikimedia Commons Dispatch/Decision Reytan, Wikimedia Commons Delivery ? Valerie Everett, flickr Drug Decision Andrew Ciscal, Wikimedia Commons Data Paramedics Worldwide, Wikimedia Commons Door/Triage 8
  9. 9. Goals   Stroke definitions   Management of TIA   Management of Ischemic Stroke – management of hyper-acute stroke 9
  10. 10. Definition of Stroke Any disease process that decreases vascular blood flow to a certain region of the brain causing neuronal cell death. 10 Source undetermined Source undetermined
  11. 11. Stroke Subtypes Ischemic 85% Thrombotic Hemorrhagic 15% Embolic Sources of images undetermined Intracerebral Hemorrhage Subarachnoid Hemorrhage 11
  12. 12. Stroke Vocabulary  TIA :  Lacunar:  “Mini-Strokes”: Symptoms <24 hrs Small infarcts TIA 12
  13. 13. Current Management of TIA Source undetermined U.S. Navy, Wikimedia Commons Mvhayes, Wikimedia Commons Novic84, Wikimedia Commons 13
  14. 14. Current Management of TIA All new onset TIAs should be admitted!!! 14
  15. 15. Short-term Prognosis after ED Diagnosis of TIA   Cohort study   1707 patients w/ TIAs   Followed for 90 days   3/97-2/98   16 EDs   10.5% stroked   1/2 w/in 2 days   25% had: – Stroke/TIA – Cardiac hospitalization – Death 15 Johnson et al: JAMA 2000;284
  16. 16. Independent Risk Factor of Stroke within 90-days of a TIA Odds Ratio P value Age>60 1.8 .01 Diabetes 2.0 <.001 >10 min duration 2.3 <.005 Weakness 1.9 <.001 Speech 1.5 .01 16 Johnson et al: JAMA 2000;284
  17. 17. 90-day Stroke Risk by Number of Risk Factors # Risks Factors Patients N= Stroke w/in 90 days 0 22 0% 1 179 3% 2 509 7% 3 584 11% 4 337 15% 5 76 34% 17
  18. 18. Medical Interventions in Patients with TIAs Atrial fibrillation Warfarin, Aspirin Heparin, Carotid stenosis Endarterectomy, Cardiovascular r/o MI event Thrombolysis, Stroke inHeparin, evolution Endarterectomy 18
  19. 19. Exceptions to the Rule   PMH of Stroke/TIA –  Negative ED CT –  recent negative stroke w/u –  Close Follow-up   Minimal symptoms of short –  w/ negative ED w/u –  Negative doppler or MRA –  +Echo –  Antiplatelet agent –  Close Follow-up duration 19
  20. 20. Current Management of TIA All new onset TIA’s should be admitted!!! 20
  21. 21. 65 y.o. Fire Chief w/ Lt arm numbness & weakness X 15 minutes   Has 15 minutes of symptoms now normal   Wife takes him to ED   Now refuses to be evaluated Naval History and Heritage Command, flickr 21
  22. 22. Management of Ischemic Stroke  Diagnostic tests  Anticoagulation  BP management Source undetermined 22
  23. 23. Diagnostic Tests  Priority studies  Recommended studies  Elective studies 23
  24. 24. Priority Studies dextrostick Source undetermined Novic84, Wikimedia Commons 24
  25. 25. 44 y.o male “found down” while cutting lawn   Last seen 1hr to 911   Rt arm/leg weakness   Hx of HTN, DM, old resolved stroke cduruk, flickr 25
  26. 26. Recommended Studies  CBC with platelets  Basic Metabolic Panel  PT & INR  CXR  U/A 26
  27. 27. Individualized Tests  Cardiac  VDRL enzymes  Antithrombin III antibodies  Protein C & S deficiency  Antiphospholipid antibodies 27
  28. 28. Anticoagulation and parsecs to go, flickr   Heparin, aspirin, ticlopidine, clopdiogrel, dipyridamole, warfarin   Commonly used   Unproven efficacy in acute stroke 28
  29. 29. Antiplatelet Agents (aspirin, ticlopidine, clopdiogrel, dipyridamole)  Long-term reduction in stroke  Long-term reduction in cardiovascular events  Not proven in acute stroke and parsecs to go, flickr 29
  30. 30. Antiplatelet Agents (aspirin, ticlopidine, dipyridamole, clopdiogrel*) Event Risk Reduction Non-fatal Stroke 25% Non-fatal MI 35% Vascular death 15% Death any cause 15% 30
  31. 31. Heparin  Commonly used in acute setting  No data supporting it’s use 31
  32. 32. International Stroke Trial (IST)   467 Hospitals   19,435 Patients Heparin   Factorial Design –  Heparin 5,000/12,500 IU –  Avoid Heparin –  Aspirin –  No Aspirin   Treatment –  w/in 48 hrs –  for 14 days Jcb10, Wikimedia Commons 32 Lancet 1997:349
  33. 33. International Stroke Trial: Results Heparin No Heparin (N=9717) (N=9718) Events preventable per 1000 Ischemic Stroke (recurrent) 2.9% 3.8% 9* Hemorrhagic Stroke 1.2% 0.4% -8* Death or Non-fatal Stroke 11.7% 12% 4 Dead or Dependent 62.9% 62.9% 0 Transfused or fatal hemorrhage 1.3% 0.4% -9* * 2p<0.05 33 Lancet 1997:349
  34. 34. 1989 Survey of Neurologist Regarding Heparin Use   82% might decrease recurrent emboli   70% might be indicated in progressing stroke   6% thought proven useful   16% thought proven ineffective 34 Marsh et al: Neurology 1989
  35. 35. High Risk Stroke/TIA Patients   Crescendo TIAs   Vertebrobasilar TIA   High grade carotid stenosis   Carotid / verterbral dissection   Small cardioembolic stroke 35
  36. 36. HEPARIN 36
  37. 37. Thrombolytic Candidates  Can treat patients who are on aspirin  Avoid antiplatelet & anticoagulants X 24 hrs following thrombolysis 37
  38. 38. Blood Pressure Management   Non-Thrombolytic Candidates   Thrombolytic Candidates – pre-treatment Mvhayes, Wikimedia Commons   Thrombolysied Patients –  during & post-treatment 38
  39. 39. Blood Pressure Management In Stroke   Guidelines in old ACLS (Advanced Cardiac Life Support) Handbook   In ACLS cards that come with new handbook 39
  40. 40. BP Management for Non-Thrombolytic Candidates  Recheck blood pressure  DON’T TREAT acutely! 40
  41. 41. cc/min/gm 120/60 (MAP=80) 41 Source undetermined
  42. 42. Current Guidelines  Recheck BP  Treat: – Systolic BP >220-230 – Diastolic BP >120-130  Reduce gradually 42
  43. 43. BP Management for Thrombolytic Candidates   Pre-Treatment – Be gentle » Systolic 185> » Diastolic110>   During/Post-Tx – Be aggressive » Systolic 185> » Diastolic105> 43
  44. 44. BP Management  Non-Thrombolytic Candidate – Don’t Treat!!!  Pre-Thrombolysis – Be Gentle!!!  During & Post-Thrombolysis – Be Aggressive!!! 44
  45. 45. 41y.o male w/ Lt eye deviation & drooling. RN notes initial BP= 200/110   Brought to ED 5 hrs. after onset   Lt. Eye deviation, drooling, slurred speech   RN notes elevated BP=200/110 45
  46. 46. Key Points  Admit all new onset TIAs  Avoid heparin use  Treat only extreme HTN 46
  47. 47. 70 y.o. female w/ Rt. sided weakness. RN notes initial BP= 200/110  Last seen normal 5 hrs. PTA  Slurred speech, Rt arm & leg weakness  RN notes elevated BP 47
  48. 48. Effectiveness of Heparin In Progressive  Phase 1: – Late 1970’s – 310 patients – ↓speech/motor between 2 exams – No Heparin  Phase 2: – Late 1980’s – 907 patients – 2 pt. ↓in SSS – Heparin infusion » No bolus » aPTT=50-80 48 Journal Internal Med 2000:248
  49. 49. 41y.o male w/ Lt eye deviation & drooling. RN notes initial BP= 200/110   Brought to ED 5 hrs. after onset   Lt. Eye deviation, drooling, slurred speech   RN notes elevated BP=200/110 49

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