This is a presentation for Stroke education targeted for hospitals, EMS providers, physicians, nurses, allied health providers and local community officials.
3. Saint Luke’s Neuroscience Institute
Stroke
Brain Tumor
Epilepsy
Minimally Invasive Spine
Movement Disorder
Rehabilitation
Brain Fitness
2
4. Regional Networking
Treats > 1000 ischemic
and hemorrhagic strokes
annually
Come by helicopter or
ambulance from more
than 80 regional hospitals
Acute Treatment Rate
Over 30%
6. 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
9. 2
Review of Cerebral Anatomy
Cerebellum - maintain balance and
further control of movement and
coordination.
10. 2
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
16. Anterior Cerebral Artery
• It supplies the frontal lobes, the parts of the brain that control
logical thought, personality, and voluntary
movement, especially the legs.
20. Middle Cerebral Artery
2
• It supplies a portion of the frontal lobe and the lateral surface
of the temporal and parietal lobes, including the primary
motor and sensory areas of face, upper extremities and
speech area. Most often occluded in stroke.
21. MCA Stroke Symptoms
2
• >Arm and face
weakness
• Aphasia
– Left dominant
• Broca – difficulty
speaking
• Wernicke – difficult
understanding
– Right dominant
• Neglect
32. 2
Three Stroke Types
Ischemic
Stroke
Clot occluding
artery
Intracerebral
Hemorrhage
Bleeding
into brain
Subarachnoid
Hemorrhage
Bleeding around
brain
Focal Brain Dysfunction
Diffuse Brain Dysfunction
33. Brainstem Typical Signs:
Cranial Nerve and Other Deficits
Oropharyngeal
Weakness:
Dysarthria
(speaking), Dysphagia
(swallowing)
Eye Movement
Abnormalities:
Diplopia
Dysconjugate Gaze
Gaze Palsy
(horizontal gaze
deficit or gaze
preference)
Decreased LOC
Nausea, Vomiting
Hiccups, Abnormal
Respirations
Vertigo, Tinnitus
34. Brainstem Typical Signs:
Bilateral Abnormalities
Quadriparesis
Sensory Loss in
All 4 Limbs
“Locked In
Syndrome”
Cranial Nerve
Signs
Crossed Signs
(1 side of face and
contralateral body)
Hemiparesis
Hemisensory Loss
35. Cerebellum Typical Signs:
Lack of Coordination
Ipsilateral (same
side) Limb Ataxia
(dyscoordination)
Truncal or Gait
Ataxia (imbalance)Tremors, or Limb
Ataxia, result from
lack of coordination of
opposing muscle groups
(flexors vs.
extensors), causing
the muscle groups to
fight each other
36. Left (Dominant) Hemisphere Typical Signs: Right
Side Weakness and Aphasia
Aphasia
Left Gaze
Preference
Right Hemiparesis
Right Hemisensory
Loss
Right Visual Field
Deficit
Hemiparesis: weakness
or partial paralysis
Hemiplegia: paralysis
Due to pathology – if
left hemisphere
stroke (right muscles
become paralyzed)–
so only muscles
working are the left.
37. Right (Nondominant) Hemisphere Typical
Signs: Left Side Weakness
Right Gaze Preference
Left Hemiparesis
Left Hemisensory
Loss
Left Hemi-inattention
(Neglect)
Left Visual Field
Deficit
Due to pathology – if
right hemisphere
stroke (left muscles
become paralyzed)–
so only muscles
working are the left.
38. Stroke Severity Scoring
• Stroke Severity required on all stroke within
one hour of admission.
1.NIH – on ALL strokes
2.ICH Score – Intracerebral Hemorrhage
3.Hunt and Hess – Non traumatic SAH
(aneurysm)
42. 2
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.
43. 2
Last time known well
Routing plan
Local-ready?
Bypass or not?
TCD—Local or state?
44. 2
Last time known well
Routing plan
Local-ready?
Bypass or not?
Is your local facility stroke ready?
46. 2
Door to Neurological Assessment….10 min
Door to CT….25 min
Door to CT/Lab interpretation….45 min
Door to Drug….60 min
The Golden Hour of Stroke Treatment
47. 2
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
55. 2
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
58. 2
“ 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”
60. 2
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
64. 2
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
71. 2
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
74. 2
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
76. 2
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
77. 2
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
78. 2
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
79. 2
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
84. What does a mulligan have in
common with a TIA?
2
85. TIA Statistics…
2
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
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
91. 2
• 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
92. 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
93. 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
95. 63 Referring Hospitals
90% >10
miles
63% >50
miles
25% >
100 miles
2
29 Critical Access
Hospitals of <25 beds
96. Results
Mean Age - 67.5 years
Mean admission NIHSS
score - 10.4
Mean discharge NIHSS
score - 3
2
97. Blood Pressure on Arrival
1
SICH
• BP=183/77
• Mortality
No
hemorrhage
• BP=232/84
• Mortality
10/14
• mRS 0-2 at
90 days
2
9.6% had BP
>180/105
98. Hemorrhage on Arrival
4
• 4 (2.7%) cases had SICH on arrival
• 3 of these had BP <180/105
2
• 2 mortalities related to SICH
• 1 mortality had BP>180/105
2
• Admit NIHSS 25; discharge NIHSS 4
• Admit NIHSS 18; discharge NIHSS 10
2
99. 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
100. 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
105. 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
Solitaire Device
