5. Regional Networking
Treats > 1000 people
ischemic and hemorrhagic
stroke annually
Come by helicopter or
ambulance from more
than 80 regional hospitals
Acute Treatment Rate
Over 30%
7. Did you know?
Stroke ranks 4th in cause of death in the U.S.
Leading cause of serious, long-term disability
$72 billion spent on stroke care per year
2
10. Review of Cerebral Anatomy
Cerebellum - maintain balance and
further control of movement and
coordination.
2
11. Review of Cerebral Anatomy
• Brain Stem - automatic
functions, such as control
of respiration, heart
rate, and blood
pressure, wake-
fullness, arousal and
attention.
LOC – most sensitive
indicator of cortical
function
2
16. Vertebral Arteries
• originate from subclavian
• ascend up spinal process
and form the Basilar
artery
• Supplies spinal
cord, brainstem, posterior
lobes
2
21. Three Stroke Types
Focal Brain Dysfunction
Ischemic Intracerebral Subarachnoid
Stroke Hemorrhage Hemorrhage
Clot occluding Bleeding Bleeding around
artery into brain brain
Diffuse Brain Dysfunction
2
22. Right (Nondominant) Hemisphere Typical Signs:
Left Side Weakness
Left Hemi-inattention
(Neglect)
Left Visual Field
Right Gaze Preference Deficit
Due to pathology – if
right hemisphere Left Hemiparesis
stroke (left muscles
become paralyzed)– Left Hemisensory
so only muscles Loss
working are the
right.
2
23. Left (Dominant) Hemisphere Typical Signs: Right Side
Weakness and Aphasia
Right Visual Field Aphasia
Deficit
Left Gaze
Preference
Due to pathology – if
Right Hemiparesis left hemisphere
stroke (right muscles
Right Hemisensory become paralyzed)–
Loss so only muscles
working are the left.
Hemiparesis: weakness
or partial paralysis
Hemiplegia: paralysis
2
24. • News reporter with aphasia
http://www.youtube.com/watch?v=xC2nC6NPY
p4
2
25. Cerebellum Typical Signs:
Lack of Coordination
Ipsilateral (same
side) Limb Ataxia
(dyscoordination)
Truncal or Gait
Tremors, or Limb Ataxia (imbalance)
Ataxia, result from
lack of coordination of
opposing muscle groups
(flexors vs.
extensors), causing
the muscle groups to
fight each other
2
26. Brainstem Typical Signs:
Cranial Nerve and Other Deficits
Decreased LOC Vertigo, Tinnitus
Nausea, Vomiting
Hiccups, Abnormal
Respirations Eye Movement
Abnormalities:
Diplopia
Oropharyngeal Dysconjugate Gaze
Weakness: Gaze Palsy
Dysarthria (horizontal gaze
(speaking), Dysphagia deficit or gaze
(swallowing) preference)
2
30. Last time known well
Routing plan
Local-ready?
Bypass or not?
This is CRUCIAL because time is the major
determinant in what interventions may be
effective—Time matters!
“Time of onset” is often difficult to
determine, so we default to the level of “time
last known well”…Most of the TIME.
2
31. Last time known well
Routing plan
Local-ready?
Bypass or not?
TCD—Local or state?
2
32. Last time known well
Routing plan
Local-ready?
Bypass or not?
Is your local facility stroke ready?
2
33. Last time known well
Routing plan
Local-ready?
Bypass or not?
2
34. The Golden Hour of Stroke Treatment
Door to Neurological Assessment….10 min
Door to CT….25 min
Door to CT/Lab interpretation….45 min
Door to Drug….60 min
2
35. Saint Luke’s Stroke Treatment Options
IV tPA…….up to 3-4.5 hours
Intra-arterial tPA.......up to 6 hours
Mechanical clot retrieval.......up to 8 hours
Wake-up stroke treatment options available
Clipping or Coiling of ruptured aneurysms within 24 hours
Clinical Trials
2
46. Saint Luke’s Stroke Treatment Options
IV tPA…….up to 3-4.5 hours
Intra-arterial tPA.......up to 6 hours
Mechanical Clot retrieval.......up to 8 hours
Wake-up stroke treatment options available
Clipping or Coiling of ruptured aneurysms within 24 hours
Clinical Trials
2
48. MRI Perfusion
NIHSS 3 at 24 hours post-intervention
Discharged with home health
2
49. “ We wanted my mom to go
to her community
hospital…….the EMS crew
said we needed to go to
Saint Luke’s for stroke care
and we are so thankful we
listened”
2
51. 86 female
Sudden worst headache of
her life
Decreased LOC
Visual disturbance
Right-sided weakness
Aphasia
PMH: heart and lung disease and
recently quit smoking
2
55. Saint Luke’s Stroke Treatment Options
IV tPA…….up to 3-4.5 hours
Intra-arterial tPA.......up to 6 hours
Mechanical Clot retrieval.......up to 8 hours
Wake-up stroke treatment options available
Clipping or Coiling of ruptured aneurysms within 24 hours
Clinical Trials
2
62. 74 y/o male
EMS called at 0630 when
wife found him
Right hemiplegia
Aphasia
Last known w/o stroke
symptoms: 8pm the night
before
PMH: renal disease, diabetes, htn,
pacemaker & PVD
2
65. Saint Luke’s Stroke Treatment Options
IV tPA…….up to 3-4.5 hours
Intra-arterial tPA.......up to 6 hours
Mechanical Clot retrieval.......up to 8 hours
Wake-up stroke treatment options available
Clipping or Coiling of ruptured aneurysms within 24 hours
Clinical Trials
2
67. Pt. experienced vtach during procedure
and converted without meds
NIHSS 9 at 24 hours post-procedure
He remained in the ICU longer than
normal due to complicated medical
history, but recovered well from his
stroke
2
68. Case Study #4
79 y/o right-handed female
Sudden onset of right-sided weakness
at 1030
EMS transported to local ED
Hx: Diabetes, CAD, Dyslipidemia, Stroke
2
69. No acute CT findings
No exclusion criteria identified
Phone consult with Neurology at SLH
Collaborative decision made to start
IV tPA and immediately transfer for
possible further intervention
2
70. Saint Luke’s Stroke Treatment Options
IV tPA…….up to 3-4.5 hours
Intra-arterial tPA.......up to 6 hours
Mechanical Clot retrieval.......up to 8 hours
Wake-up stroke treatment options available
Clipping or Coiling of ruptured aneurysms within 24 hours
Clinical Trials
2
72. CT Head
No acute findings
Complete Resolution of
Neurological Deficits
Discharged Home
2
73. The Challenge
Increase Access to IVtPA Safely
• Stroke treatment with IVtPA is time dependent
• Patients will most likely present to the closest hospital
• Earlier treatment is associated with better outcomes
• The presenting hospital may be able to administer IVtPA but
cannot provide intensive monitoring during first 24 hours
• The patient is transferred to a more comprehensive center
• Transfer protocols with IVtPA running are not standardized
• Is it safe to “ship” the patient immediately after starting tPA?
2
74. Is Immediate Transport Safe?
• Retrospective review of consecutive “drip and
ship” cases 2008-2010.
• Analysis
– SICH or BP>180/105 on arrival
– Inaccurate stroke diagnosis
– Need for intra-arterial (IA) treatment
– Mortality rate
– Clinical outcome (mRS at 90 days)
• Location and Size of referring hospital
2
75. Results
145 (20%) of
1626 ischemic 717 (44%) were transferred
strokes transferred cases were
“drip and ship”
2
76. 63 Referring Hospitals
90% >10
miles
63% >50
miles
25% >
100 miles
29 Critical Access
Hospitals of <25 beds
2
77. Results
Mean Age - 67.5 years
Mean admission NIHSS
score - 10.4
Mean discharge NIHSS
score - 3
2
78. Blood Pressure on Arrival
1 • BP=183/77
SICH • Mortality
9.6% had BP No • BP=232/84
hemorrhage
>180/105 • Mortality
• mRS 0-2 at
10/14 90 days
2
79. Hemorrhage on Arrival
• 4 (2.7%) cases had SICH on arrival
4 • 3 of these had BP <180/105
• 2 mortalities related to SICH
2 • 1 mortality had BP>180/105
• Admit NIHSS 25; discharge NIHSS 4
2 • Admit NIHSS 18; discharge NIHSS 10
2
80. Outcomes
mRS 0-2 at 90 days = 72/114 (63%)
Note: mRS scores not available for 2008
Mortality = 20/145 (13.7%)
IA therapy = 35/145 (24%)
Inaccurate diagnosis at sending facility = 6/145 (4.1%) ; all had
excellent clinical outcomes.
2
81. Gtt & Ship Data
• Immediate transport of patients with IV tPA infusing
is safe with a low incidence of SICH en route
• >90% had BP <180/105 on arrival
• The 63% good outcomes may, in part, relate to early
treatment with IV tPA in referring hospitals
• Hospitals of every size and location can safely treat
stroke victims with IV tPA if they have access to
consultation and transfer agreements with
experienced stroke centers
2
84. What does a mulligan have in
common with a TIA?
2
85. TIA Statistics…
10% of all strokes are preceded by TIAs
1/3 of all persons who experience TIAs…will go on
to have an actual stroke
• 5% of those strokes will occur within ONE month
• 50% within 48hours
2
87. Mild Stroke
NIH Stroke Scale: stroke severity scale (0-42)
<5 Mild impairment
10-20 Moderate impairment
>20 Severe impairment
Predicted need for long-term nursing care
<6 Most will return home
6-13 Most will need short-term hospital care
>13 Most will need long-term nursing care
2
90. • Post IV tPA Treatment & Management
• Document neuro assessment & blood pressure Q15min
• If change in neuro: STOP tPA, assess ABC’s & vitals & glucose
• Maintain BP<180/105 after administration and during transport
• Hypertension: Labetalol 10mg IV over 2min. Recheck in 5min; may
repeat x1 (do not use if heart rate <60)
• Stop BP infusion if SBP<140 or DBP<80
• Hypotension: STOP tPA, HOB flat, turn off drips, 500ml fluid
bolus(NS), reassess
• Start NS at 80ml/hr after infusion complete to clear line and continue if
no hx of CHF
2
95. Solitaire Device
Outcomes for patients who received treatment with the
Solitaire system during clinical trial:
• Brain artery opened 83% of the time in
comparison to 48% with the Merci
retriever catheter
• Good clinical outcomes 58% of the time
vs. 33% with Merci
• 55% reduction in patient mortality at 3
months using Solitaire vs. Merci
