Acute Stroke:Recognizing and Reacting

Dr. Grant StottsStroke Neurologist, Ottawa Hospital

Stroke and MI

• Share many common causes– Blood pressure, smoking, cholesterol ...

• Both result in blood clots stopping circulation– Therefore, acute treatment may involve

similar approaches

Presentation Goals

• Review the signs of stroke

• Emphasis the crucial role fast response plays in stroke treatment

• Recognize potential of available treatments– Acute– Preventative

Warning Signs of Stroke

1. Weakness

2. Troubles Speaking

3. Vision Problems

4. Sudden Headache

5. Dizziness

Updated October 2006

Warning Signs of Stroke

• Weakness– Sudden loss of strength or sudden

numbness in the face, arm or leg, even if temporary

Updated October, 2006

Warning Signs of Stroke

• Trouble Speaking– Sudden difficulty speaking or

understanding or sudden confusion, even if temporary.

Updated October, 2006

Warning Signs of Stroke

• Vision Problems– Sudden trouble with vision, even if

temporary.

Updated October, 2006

Warning Signs of Stroke

• Headache– Sudden severe and unusual headache.

Updated October, 2006

Warning Signs of Stroke

• Dizziness– Sudden loss of balance, especially with

any of the above signs.

Stroke Warning Signs

• Stroke recognition is impaired by:– Lack of awareness– Lack of pain

WeaknessTroubles SpeakingVision Problems

HeadacheDizziness

A Stroke in Ottawa

A Stroke in Ottawa• Identify possible stroke

• Alert EMS

• Immediate transport

• Immediate triage (stroke code)– Initiates calls to CT

room, neurologists– Necessary blood work

is done– Patient taken to CT

(computerized tomography) scanner

Normal CT

CT With a Stroke

CT With a Bleed

Acute Stroke TreatmenttPA• If no bleed and < 3

hours, considered for acute treatment

• Standard is presently tPA - intravenous– Improves relative

chance of survival or reduced disability by about 30%

– Risk is bleeding (about 6% of those who receive it)

Time is Everything

• Time is the most important factor– Nothing else is

more important to open up the artery

Intra-arterial tPA• Intraveneous tPA is limited to

being given within 3 hours• SELECT patients from 3 to 6

hours may qualify for intra-arterial therapy– Guiding a catheter through the

arteries up to the clot and giving a small dose of tPA

– Similar to heart attacks, angioplasty and stenting can now be done in certain vessels

MR Angiogram

Blocked middle cerebral artery Restored flow

MERCI DEVICE

• More recent option is to remove the clot (mechanical extraction)– MERCI Device– Currently available in

Ottawa• Used in SELECT cases where

tPA is felt unlikely to work• Made popular by ER

APM0097_A_1991

Merci RetrieverMerci Retriever

APM0097_A_1991

Merci System AnimationMerci System Animation

Courtesy: Dr. M. Sharma

Telestroke TechnologyTelestroke Technology

Efilm Server

Base Hospital

RemoteHospital

ISDN or VPN

VPN

Research Presently Taking Place

Desmoteplase

New agent for breaking up blood clots

Given IV

Similar to tPA

• sICH Low = Stringent Dependence on Fibrin • Therapeutic window 9hr• Low Fibrinogenlysis• t1/2 = 138 min

DesmoteplDesmoteplasease• Desmodus rotundus

• Vampire Bat Salivary PA• Recombinant DSPAα1• High Fibrin Selectivity

CT Perfusion Imaging in Acute Stroke – Ischemic CT Perfusion Imaging in Acute Stroke – Ischemic PenumbraPenumbra

0

2

4

6

8

10

CBV (ml/100g)0

26

52

78

104

130

CBF (ml/100g/min)0

6

12

18

24

30

MTT (sec)

CBV CBF MTT

How Well Are We Doing Now?

Courtesy: Dr. Michael Sharma, Medical Director Stroke Program, The Ottawa Hospital

Ontario tPA Rates by HospitalOntario tPA Rates by Hospital20032003

A B C D E F G H I J K L M N O P Q R S T U0.0

5.0

10.0

15.0

20.0

25.0

30.0

% of N

tPA %

Overall tPA Rate 9% (Ischemic Patients)

Overall tPA Rate 9% (Ischemic Patients)

N = 4,107

Improvements

• Presented here by Dr. Sharma 2003– Increase awareness of stroke signs

• Heart and Stroke Ad Campaigns

– EMS directed to hospitals with stroke teams

– Stroke code protocols in ER– Neurologists on call

Courtesy: Dr. M. Sharma

0

2

4

6

8

10

12

14

16

18

20

Rate (Ischemic Stroke)

V A B L I M K C J

Site

tPA rate July-Sept 2004

Series1

Canadian and Ontario Stroke Strategies

Best Practice across the Continuum of Care

The Ontario Stroke System

Stroke Strategy Principles:•Comprehensive•Integrated•Evidence-based•Province Wide

Stroke recognition

Prevention

Prehospital

Emergency Acute

Rehab

Community

Transition

Stroke in Canada

• The leading cause of adult disability • 4th leading cause of death• One stroke every ten minutes in Canada• 50,000 strokes per year• 20,000 new strokes in Ontario per year• 300,000 stroke survivors• 28% of stroke patients are under age 65

Statistics CanadaKiely DK, et al. Stroke 1993;24:1366-

1371

Cost of Stroke

• The cost of the disease is more than $3 billion a year in Canada

• Stroke has longest LOS of any disease

• The rate of hospitalization for stroke is over 20 times higher for those 65 and over

• Average acute care cost estimated at $27,500

Outcome of Ischemic Stroke

Dead15%

Moderate Disability

15%Minor

Disability30%

Full Recovery

25%

MajorDisability

15%

Adapted from Stegmayr B, et al. Stroke 1997;28:1367-1374

11 Regions9 Regional Stroke Centres

2 Enhanced District Stroke Centres16 District Stroke Centres

24 Stroke Prevention Clinics

Champlain Region

The Champlain District (1.2 million)

Impact of an integrated strategy: The Ontario Stroke Strategy

54% increase in patients receiving referrals to stroke prevention clinics following initial stroke/TIA to prevent more serious event (there are now 24 prevention clinics in Ontario)

tPA: A clot-busting drug - the only proven treatment in stroke:– Average tPA rate increased from 25% to 34% in

designated regional stroke centres

Inpatient admissions for stroke decreased by 11%, mostly attributable to a decrease in admissions for transient ischemic attacks (TIA) or small strokes

2005 Evaluation of the Ontario Stroke Strategy - comparisons made between 2000 (before the Ontario Stroke Strategy was implemented) and 2003 (after the strategy was implemented)

Impact of an Integrated Strategy

Number of patients now managed on specialized stroke units increased from 18% to 60%

Decreased utilization in inpatient resources

Physiotherapy assessments before hospital discharge have increased from 47% to 75%, and occupational therapy consults from 38% to 71%

85% of patients discharged on antiplatelet medications to help prevent another stroke

8.7% of patients require admission to long-term care - major decrease from two years previously

Economic impact of an integrated stroke strategy

Based on current Canadian population, the net benefit of providing coordinated stroke care, over next 20 years:

– Prevent 160,000 strokes– Prevent disability in 60,000 Canadians– Achieve net savings of $8 billion

Economic analysis is very conservative - does not include:– primary prevention interventions other than hypertension,– secondary prevention clinics, and – improved post-acute rehabilitation

Projected impact would be significantly higher

Source: Dr. Mike Sharma (in partnership with Caro Research) - based on systems changes implemented through the Ontario Stroke Strategy, extrapolated for all of Canada, multiple data sources

Awareness of Stroke Warning Signs

Aware of 2 or moresigns

Aware of keywarning signs

DizzinessVision problemsTrouble speakingHeadache

2003(%)2005(%)52 72

43 6225 4523 4129 32

Ottawa Performance2006• Stroke patients arriving in ER within

2.5 hours– 42.5%

• If patient arrives within 2.5 hours, chance of getting tPA– 47%

• Stroke patients arriving by ambulance– 57.5%

What If The Symptoms Are Temporary?

TIA Management

• TIA is the equivalent of angina– Warning sign of stroke

Gladstone et al, CMAJ, 2004, Mar 30:170(7):1099

Risk of Stroke After TIA

Ottawa Stroke Prevention Clinic• All TIA patients triaged for rapid

referral– Carotid doppler and echocardiogram– Placed on antiplatelet therapy– Options for statins and BP agents

provided

Summary

• Effective treatments exist for stroke

• The key to acute treatment is TIME– Recognition of stroke symptoms– Activation of EMS– Rapid triage of minor and serious

strokes/TIAs

Warning Signs of Stroke

1. Weakness

2. Troubles Speaking

3. Vision Problems

4. Sudden Headache

5. Dizziness