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2016: National Acute Stroke Protocol Standard of Care and Emerging Technology-Osborne
1. National Acute Stroke Protocol
Standard of Care & Emerging Technology
Thomas F. Osborne, MD
Neuroradiologist @ Virtual Radiologic, Director of Medical Informatics @Virtual Radiologic, Director Of Research @ MEDNAX
Third Annual Clinical Geriatrics Interprofessional Symposium 12/3/16
2. Financial Disclosure
I do not have direct or indirect financial
interest in the equipment or medications
discussed in this lecture
6. Photo credit:
New York Times: Collect Debts, Nursing Homes Are Seizing Control Over Patients. Jan 25,
2015
What is happening to my wife!?
What can we do?
What is going to happen next?
11. Hippocrates
• Saw stroke as an act of swift
and terrible violence by the gods
(to strike -- a stroke).
• Poorly understood, it came to be
called "apoplexy," derived from
the Greek for "crippling stroke"
as from a powerful weapon.
• For centuries, apoplexy was
generally used to describe any
act of paralysis.
460 BC –370 BC
Thomas Osborne, MD
12. Johann Jacob Wepfer
• Hypothesized from his autopsy
studies that stroke was due to
bleeding in the brain.
• The first to suggest stroke might be
caused by a blockage in a blood
vessel.
• 1658 published a classic treatise
regarding strokes, titled Apoplexie.
1620 -1695
Thomas Osborne, MD
13. Rudolf Ludwig Carl Virchow:
Virchow’s triad (as a model) though technically a venous concept
• Vascular endothelial injury
• Hypercoagulability
• Stasis
Schiller F. Concepts of stroke before and after Virchow. Medical history. 1970 Apr 1;14(02):115-31.
1821– 1902
14. Cause of Ischemic Stroke
ASD, PFO, VSDASD, PFO, VSD
Vascular endothelial injury
Stasis
Hypercoagulability (all)
Other causes:
Vasospasm (SAH, Rx) chronic meningitis, arteritis, Moya-moya, cardiac arrest, etc.
15. Reference:
Fisher M, Dávalos A, Rogalewski A, Schneider A, Ringelstein EB, Schäbitz WR. Toward a multimodal neuroprotective treatment of stroke. Stroke. 2006 Apr 1;37(4):1129-36.
18. Thomas Osborne, MD
• Earliest recanalization attempts failed
• Before CT and many pts after 6h + Hemorrhage
• By the 1970’s considered too dangerous
• 1980’s success in other areas renewed interest
• PE, MI, & better cath design
• 1980-1990 trials and errors
• (ASK) Australian Streptokinase Trial
• (MAST-E) Multicenter Acute Stroke Trial-Europe
• (MAST-I) Multicenter Acute Stroke Trial-Italy
• (ECASS) European Cooperative Acute Stroke Study
• NINDS 1995 rtPA Stroke Study
• B/c the NINDS study, in 1996 FDA approved tPA
» National Institute of Neurologic Disorders and Stroke
» tissue recombinant plasminogen activator (fibrinolytic)
19. NINDS Summary
(National Institute of Neurologic Disorders and Stroke)
– Don’t give tPA if head CT = risk for bleed
– If you give IV tPA before 3 hr = pts do better
– If you give after 3 hr = inc risk for ICH
Reference:
Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;14;333:1581-1587.
20. Reference:
Jauch EC, Saver JL, Adams HP, Bruno A, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR.
Guidelines for the early management of patients with acute ischemic stroke a guideline for healthcare professionals
from the American Heart Association/American Stroke Association.
Stroke. 2013 Mar 1;44(3):870-947.
http://stroke.ahajournals.org/content/44/3/870
Time Goals
21. 67yo M c 2h of AMS weakness
Initial Question:
Is it a stroke or stroke mimic?
– Hypoglycemia, Seizure, Bell’s palsy, Rx, ICH, MS,
Migraine, Thiamine Deficiency, Tumor, Infection,
underlying medical illness, other illness…
Baseline condition?
22. Photo credit: New York Times
Interdisciplinary Collaborative Team
Code stroke called in field
Immediate/EMS: NIH Stroke Scale, initial labs & Hx of contraindications
Acute triage and directly to CT scan
Pt eval in ED or in CT. Premix tPA
Rapid CT eval and rapid Rx (in CT room)
24. Reference:
Jauch EC, Saver JL, Adams HP, Bruno A, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR.
Guidelines for the early management of patients with acute ischemic stroke a guideline for healthcare professionals
from the American Heart Association/American Stroke Association.
Stroke. 2013 Mar 1;44(3):870-947.
http://stroke.ahajournals.org/content/44/3/870
* A physician with expertise in
acute stroke care may modify this list.
25. Reference:
Jauch EC, Saver JL, Adams HP, Bruno A, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR.
Guidelines for the early management of patients with acute ischemic stroke a guideline for healthcare professionals
from the American Heart Association/American Stroke Association.
Stroke. 2013 Mar 1;44(3):870-947.
http://stroke.ahajournals.org/content/44/3/870
39. Core (DWI)Penumbra
Severely dec flow
Rapid irreversible damage
-Excitotoxic
-Necrotic cell death
Ischemic but noninfarcted
Potentially salvageable
Collateral support
Cell death slower
Size = physiology
-(Huge target for Rx)
Sometimes just perfusion defect
-TIA, carotid stenosis
Basic Pathophysiology
Thomas Osborne, MD
49. Summary
1. Patient Presentation
• What to look for and answering immediate questions
1. Stroke Stats
• 4th-5th
common cause of death. 1 stroke/40 seconds
1. Pathophysiology
• Emboli, Ischemia and Infarction
1. Rx / National Stroke Protocol
• tPA 3 hours from onset
1. Advanced Technology/Terms
• Imaging physiology: Core and Penumbra, Stroke Scale
1. Prehospital Evaluation
• Time is brain
Thomas Osborne, MD
Sudden onset of an unexplainable neurological disability
1/3 territory: ECASS: Euro Coop Acute Stroke Study. NINDS: National Inst of Neuro Disorders & Stroke.
Delta R2* = the change in the rate of T2* relaxation compared to baseline.
T2* relaxation is an exponential process.
MTT: Mean Transit Time (s) vs TTP
Average time for blood to move through a given voxel.
CBV: Cerebral Blood Volume (mL/100g) vs DWI
Total amount of blood in given unit volume of brain.
tissues, arteries, arterioles, capillaries, venules, & veins
dec perfusion pressure causes compensatory vasodilitation
CBF: Cerebral Blood Flow (mL/100g/min)
Volume of blood moving through unit volume of brain per unit time
Dynamic imaging with T2* & gadolinium:
Sequential T2* images aquired during first pass rapid injection of gado bolus.
Concentration of contrast within a voxel at the microvascular level
Flow = physiology
