Care of Acute Ischemic Care of Acute Ischemic StrokeStroke

Ethan Cumbler M.D.Ethan Cumbler M.D.Assistant Professor Internal MedicineAssistant Professor Internal Medicine

University of Colorado HospitalUniversity of Colorado HospitalUCH Stroke CouncilUCH Stroke Council

20082008

DisclosuresDisclosures

No conflicts in the last 3 yearsNo conflicts in the last 3 years

What do you call a group of What do you call a group of whales?whales?

A “Pod”A “Pod”

What do you call a group of crows?What do you call a group of crows?

A “Murder”A “Murder”

What do you call a group of What do you call a group of hyenas?hyenas?

A “Cackle”A “Cackle”

A 63 y/o woman with obesity, hypertension, A 63 y/o woman with obesity, hypertension, diabetes, and a pack-a-day smoking habit who diabetes, and a pack-a-day smoking habit who takes a daily baby aspirin develops acute right takes a daily baby aspirin develops acute right

sided weakness and sensory loss.sided weakness and sensory loss.

What needs to occur to have the best chance of What needs to occur to have the best chance of reversing the deficits from this stroke?reversing the deficits from this stroke?

How can we reduce the chance of complications which How can we reduce the chance of complications which would risk survival and promote disability?would risk survival and promote disability?

How do we optimize her chances of avoiding a second How do we optimize her chances of avoiding a second stroke?stroke?

Ischemic StrokeIschemic Stroke

700,000 ischemic strokes yearly700,000 ischemic strokes yearly– Approximately one stroke every 45 secondsApproximately one stroke every 45 seconds

200,000 are recurrent events200,000 are recurrent events

Leading cause of disability in the USLeading cause of disability in the US

Etiology of Ischemic Events

Cardiac, 29%

Large Vessel,

16%

Lacunar, 16%

Other, 3%

Unknown, 36%

Cardiac

Large Vessel

Lacunar

Other

Unknown

Stroke CareStroke Care

Optimally a seamless Optimally a seamless transition of events transition of events spanning the period spanning the period from recognition to from recognition to rehabilitationrehabilitation

RecognitionRecognitionPrehospitalPrehospitalEDEDHospital Care- Hospital Care- HospitalistHospitalistRehabilitationRehabilitationHomeHome

The “Stroke Chain of Survival” requires strength at The “Stroke Chain of Survival” requires strength at every linkevery link

Hyper-Acute CareHyper-Acute CareTime to tPA is highly associated with outcome.Time to tPA is highly associated with outcome.

National rates for tPA use are only 3-8%National rates for tPA use are only 3-8%

Increased from 23.5 to 40.8% for patients Increased from 23.5 to 40.8% for patients presenting within 2 hours of symptoms in presenting within 2 hours of symptoms in hospitals participating in GWTGhospitals participating in GWTG

This is a high stakes and time critical decisionThis is a high stakes and time critical decision

Hyper-Acute Care TeamHyper-Acute Care TeamMultiple elements Multiple elements must occurmust occur

When time is When time is critical, team critical, team performs tasks in performs tasks in parallel rather than parallel rather than in sequencein sequence

↑ ↑

↑ ↑ ↑↑↑↑↑↑↑↑ vsvs ↑↑

↑↑

Rapid transport to hospitalRapid transport to hospital

Early triageEarly triage

Focused historyFocused history

NIH stroke scaleNIH stroke scale

Coordinate imagingCoordinate imaging

Assessment of lytic Assessment of lytic contraindicationscontraindications

tPA risk/benefit discussiontPA risk/benefit discussion

JCAHO Quality MeasuresJCAHO Quality Measures

DVT prophylaxisDVT prophylaxis

Discharged on anti-thrombotic therapyDischarged on anti-thrombotic therapy

Patients with A-fib receiving anticoagulationPatients with A-fib receiving anticoagulation

Thrombolytic therapy administeredThrombolytic therapy administered

Anti-thrombotic therapy by hospital day 2Anti-thrombotic therapy by hospital day 2

Discharged on cholesterol-reducing medicationDischarged on cholesterol-reducing medication

Dysphagia screeningDysphagia screening

Stroke educationStroke education

Smoking cessation/advice/counselingSmoking cessation/advice/counseling

Assessed for rehabilitationAssessed for rehabilitation

JCAHO Quality MeasuresJCAHO Quality Measures

If there are 10 independent JCAHO If there are 10 independent JCAHO measures and your hospital has a 95% measures and your hospital has a 95% success rate for each one.success rate for each one.

What is the chance that a patient will What is the chance that a patient will receive all of the mandated quality receive all of the mandated quality measuresmeasures

Only 60%Only 60%

What do you call a group of otters?What do you call a group of otters?

A “Romp”A “Romp”

Management of Co-morbiditiesManagement of Co-morbiditiesGlycemic ControlGlycemic Control

Hyperglycemia present in Hyperglycemia present in 1/3 of strokes1/3 of strokesCorrelates with worsened Correlates with worsened outcomesoutcomesRecommendation is to Recommendation is to control to <200 with goal control to <200 with goal of 80-140of 80-140How to achieve this goal How to achieve this goal and whether intensive and whether intensive insulin drip therapy will insulin drip therapy will end up proving beneficial end up proving beneficial is not clearis not clear

PEARLSPEARLSRarely a need for Rarely a need for dextrose in IVF in the first dextrose in IVF in the first 24 hours24 hours

Metformin problematic-Metformin problematic-contrast/lactic acidosiscontrast/lactic acidosis

Sulfonylurea medications Sulfonylurea medications associated with associated with hypoglycemia when oral hypoglycemia when oral intake interruptedintake interrupted

Management of Co-morbiditiesManagement of Co-morbiditiesLipid ManagementLipid Management

SPARCL trial demonstrated a SPARCL trial demonstrated a 2.2% absolute reduction of 2.2% absolute reduction of recurrent stroke with statin over 5 recurrent stroke with statin over 5 yrs following CVA (16% RR).yrs following CVA (16% RR).No change in mortality and No change in mortality and interestingly a small increase in interestingly a small increase in hemorrhagic strokes*.hemorrhagic strokes*.FASTER trial failed to support FASTER trial failed to support early use of high dose statinearly use of high dose statinCholesterol lowering therapy Cholesterol lowering therapy recommended for LDL>100recommended for LDL>100

Management of Co-morbiditiesManagement of Co-morbiditiesLipid ManagementLipid ManagementHow are we doing?How are we doing?

2006 study from 11 California hospitals:2006 study from 11 California hospitals:– Lipids measured and treated in only half of ptsLipids measured and treated in only half of pts– 40% of patients meeting guidelines for lipid 40% of patients meeting guidelines for lipid

therapy were not discharged on treatmenttherapy were not discharged on treatment

Encouragingly GWTG hospitals were able Encouragingly GWTG hospitals were able to increase appropriate treatment ratesto increase appropriate treatment rates– 59% to 77% 59% to 77%

MManagement of Co-morbiditiesanagement of Co-morbiditiesHypertensionHypertension

Ischemic PenumbraIschemic PenumbraZone of at risk tissue susceptible to reduction Zone of at risk tissue susceptible to reduction below the threshold of viability in response to below the threshold of viability in response to relatively small drops in MAP.relatively small drops in MAP.

Objective of Objective of Blood Pressure ControlBlood Pressure Control

Intervention is designed to maximize perfusion Intervention is designed to maximize perfusion to the ischemic penumbra while minimizing the to the ischemic penumbra while minimizing the hypertensive risk of hemorrhagic hypertensive risk of hemorrhagic transformation.transformation.

Management of Co-morbiditiesManagement of Co-morbiditiesBlood Pressure ControlBlood Pressure Control

80% of stroke admissions have elevated BP.80% of stroke admissions have elevated BP.In the first major study on the subject, mean In the first major study on the subject, mean pressure on admit for stroke was:pressure on admit for stroke was: 214/118—patients with prior hypertension214/118—patients with prior hypertension163/90—patients without prior HTN163/90—patients without prior HTN

Even without intervention, the pressure tends Even without intervention, the pressure tends to fall 10-15% in the first 24 hours.to fall 10-15% in the first 24 hours.By day 10 BP will fall 13-20%By day 10 BP will fall 13-20%

Ischemic Stroke Pre-tPAIschemic Stroke Pre-tPA

Exclusion criteria if Exclusion criteria if relatively non-relatively non-aggressive aggressive measures have measures have failed to bring down failed to bring down to BP <185/110.to BP <185/110.

Recommended Steps:Recommended Steps:

Labetalol 10-20mg IVLabetalol 10-20mg IV

(may repeat x1) or(may repeat x1) or

Nitropaste 1-2 inches Nitropaste 1-2 inches

BP must be <185/110 for tPA.

Ischemic StrokeIschemic Stroke Post-tPA Post-tPA

Monitor BP closely.Monitor BP closely.

BP q15min x 2 hrs thenBP q15min x 2 hrs then

q30min x 6 hrs thenq30min x 6 hrs then

qhr x 16 hrsqhr x 16 hrs

Goal BP<180/105

•Avoid placing an arterial line after tPA.

About 1/3 of patients who receive tPA require antihypertensive therapy in the first day.

Choice of agent?NitroprussideLabetololNicardipineFenoldopan Nitroglycerin

Avoid sublingual nifedipine and clonidine

Ischemic Stoke Without tPAIschemic Stoke Without tPA

Choice of agent??Choice of agent??

TitratableTitratable

Avoid overcorrectionAvoid overcorrection

If BP lowered it is If BP lowered it is generally safe as generally safe as long as not long as not exceeding 10-15%exceeding 10-15%

Withhold treatment until BP >220/120

Blood Pressure

““Permissive Hypertension”Permissive Hypertension”

Chronic Blood Pressure Chronic Blood Pressure ControlControl

UK TIA study demonstrated a 28% UK TIA study demonstrated a 28% decrease in long term stroke risk for decrease in long term stroke risk for every 10mm drop in systolic BP.every 10mm drop in systolic BP.

By comparison- How much risk By comparison- How much risk reduction do you get with aspirin?reduction do you get with aspirin?

15%15%

HypotensionHypotension

Low blood pressure is rare after acute Low blood pressure is rare after acute ischemic stroke (<5%).ischemic stroke (<5%).When it occurs it is associated with poor When it occurs it is associated with poor outcome.outcome.Work-up should include evaluation for Work-up should include evaluation for dehydration, cardiogenic shock, arrhythmia, or dehydration, cardiogenic shock, arrhythmia, or dissection.dissection.First-line therapy is volume resuscitation and First-line therapy is volume resuscitation and optimization of cardiac output.optimization of cardiac output.Start vasopressors if low BP is associated Start vasopressors if low BP is associated with worsened neurologic exam.with worsened neurologic exam.

What do you call a group of What do you call a group of Porcupines?Porcupines?

A “Prickle”A “Prickle”

ComplicationsComplications64% of stroke patients in a modern stroke 64% of stroke patients in a modern stroke unit have a complication in the first weekunit have a complication in the first week– Fever 24%Fever 24%

– UTI 16%UTI 16%

– Pneumonia 11%Pneumonia 11%

– Myocardial injury 16%Myocardial injury 16%

– PE 0.6%PE 0.6%

URINARY TRACT INFECTIONURINARY TRACT INFECTION

80% of nosocomial UTIs are associated with 80% of nosocomial UTIs are associated with catheterscathetersInfection is directly related to duration of useInfection is directly related to duration of use3-10% daily incidence of bacteriurea3-10% daily incidence of bacteriureaAlternatives such as condom catheters are an Alternatives such as condom catheters are an optionoptionPhysicians unaware of catheter- 28% of casesPhysicians unaware of catheter- 28% of cases

Indwelling catheters must be removed ASAPIndwelling catheters must be removed ASAP

Prevention of ComplicationsPrevention of ComplicationsAspiration PneumoniaAspiration Pneumonia

¼ to >½ of stroke patients have dysphagia¼ to >½ of stroke patients have dysphagiaOne third of patients with aspiration will develop One third of patients with aspiration will develop pneumoniapneumoniaMore than 5-10% of stroke admissions are More than 5-10% of stroke admissions are complicated by pneumoniacomplicated by pneumonia

50% reduction in risk with formal program:50% reduction in risk with formal program:Swallow screen prior to diet/meds Swallow screen prior to diet/meds Aspiration precautionsAspiration precautionsOral careOral carePneumonia vaccinePneumonia vaccine

Prevention of ComplicationsPrevention of ComplicationsDeep Venous ThrombosisDeep Venous Thrombosis

Without prophylaxis, up to 75% of patients Without prophylaxis, up to 75% of patients with hemiplegic stroke will have evidence of with hemiplegic stroke will have evidence of DVT DVT

Effective prophylaxis can reduce the VTE Effective prophylaxis can reduce the VTE rate by 50-70%rate by 50-70%

Even with prophylaxis- venographic Even with prophylaxis- venographic evidence of VTE is present in 10-20% evidence of VTE is present in 10-20% – As much as 30% with NIHSS>14As much as 30% with NIHSS>14

With prophylaxis- 1% symptomatic VTE rateWith prophylaxis- 1% symptomatic VTE rate

Prevention of ComplicationsPrevention of ComplicationsDeep Venous ThrombosisDeep Venous Thrombosis

Stockings and SCDs offer a non-significant Stockings and SCDs offer a non-significant reduction in DVT ratesreduction in DVT ratesAnti-platelet therapy alone is NOT sufficient Anti-platelet therapy alone is NOT sufficient prophylaxis against venous thrombusprophylaxis against venous thrombusLower potency heparin prophylaxis (heparin Lower potency heparin prophylaxis (heparin 5000 U bid) appears to be less effective than 5000 U bid) appears to be less effective than higher potency prophylaxishigher potency prophylaxisHigher efficacy prophylaxis does not appear to Higher efficacy prophylaxis does not appear to confer increased risk for ICHconfer increased risk for ICH– Studies have mixed results on this issueStudies have mixed results on this issue

Early mobilization!!Early mobilization!!

Prevention of ComplicationsPrevention of ComplicationsElectrolyte DisturbancesElectrolyte Disturbances

SIADH common after intracranial eventsSIADH common after intracranial events

Hypo-osmolar state may worsen cerebral Hypo-osmolar state may worsen cerebral edemaedema

PearlPearl

Avoid hypotonic fluids in the early period Avoid hypotonic fluids in the early period post CVApost CVA

Secondary PreventionSecondary PreventionAnti-thrombotics-101Anti-thrombotics-101

JCAHO requires anti-thrombotics to be JCAHO requires anti-thrombotics to be started within 48 hoursstarted within 48 hours

Warfarin for atrial fibrillationWarfarin for atrial fibrillation

Antiplatelet therapy if non-cardioembolicAntiplatelet therapy if non-cardioembolic– ASA/Dipyridamole ERASA/Dipyridamole ER– ClopidogrelClopidogrel– ASAASA

STROKE RISK REDUCTION TRIALS Non-cardioembolic Cardioembolic

66%

14%23%

8%

18%

0%

10%

20%

30%

40%

50%

60%

70%

ASA vsPlacebo

Clopidogrelvs ASA*

DP+ASA vsASA

ASA vsPlacebo*

Warfarin vsPlacebo

COMPARISON GROUPS* risk reduction not statistically signif icant

ST

RO

KE

RE

LA

TIV

E R

ISK

R

ED

UC

TIO

N

SALT

CAPRIE

ESP-2

EAFT

EAFT

Secondary PreventionSecondary PreventionAnti-thrombotics-201Anti-thrombotics-201

Acute use of heparin has never been proven to Acute use of heparin has never been proven to improve outcomes.improve outcomes. early second ischemic stroke equally balanced by early second ischemic stroke equally balanced by

early hemorrhagic strokes early hemorrhagic strokes

Higher doses of aspirin do not provide greater Higher doses of aspirin do not provide greater benefit than low doses- benefit than low doses- UK TIA trialUK TIA trial

For arterial strokes- warfarin is not superior to For arterial strokes- warfarin is not superior to aspirin- aspirin- WARSS TrialWARSS Trial

Combination of clopidigril and aspirin does not Combination of clopidigril and aspirin does not provide benefit over monotherapy- provide benefit over monotherapy- MATCH TrialMATCH Trial

What do you call a group of What do you call a group of peacocks?peacocks?

An “Ostentation”An “Ostentation”

Strokes Occurring During Strokes Occurring During HospitalizationHospitalization

5-15% of all hospitalized stroke cases5-15% of all hospitalized stroke cases

Frequently associated with proceduresFrequently associated with procedures

1% of all MI patients will have a stroke 1% of all MI patients will have a stroke during hospitalizationduring hospitalization

Day #2 after his procedure he has Day #2 after his procedure he has sudden acute onset of severe vertigo, sudden acute onset of severe vertigo, nausea, and diplopia.nausea, and diplopia.

Nurse calls the physician listed on Nurse calls the physician listed on post-procedure orders. No answer post-procedure orders. No answer after three attempts. Nursing after three attempts. Nursing eventually determines the correct eventually determines the correct physician to call. Verbal order for physician to call. Verbal order for promethazine. promethazine.

Patient continues to complain of Patient continues to complain of severe vertigo. Nursing calls back severe vertigo. Nursing calls back physician who evaluates and orders physician who evaluates and orders non-contrast head CTnon-contrast head CT

10:00am10:00am

11:15am11:15am

3:30pm3:30pm

43 y/o in hospital for observation 43 y/o in hospital for observation after a minor GI procedure.after a minor GI procedure.

Head CT read as negative for bleed. Head CT read as negative for bleed. Based on continued symptoms Based on continued symptoms neurology called for consultation.neurology called for consultation.

Neurologist answers page but explains Neurologist answers page but explains that she is covering multiple hospitals that she is covering multiple hospitals and can not physically see the patient. and can not physically see the patient. Recommends MRI with diffusion.Recommends MRI with diffusion.

Hospitalist called for consultationHospitalist called for consultation

MRI/MRA orderedMRI/MRA ordered

4:304:30

4:454:45

5:005:00

5:255:25

Case StudyCase Study

Radiology indicates MRI no Radiology indicates MRI no longer available as technician longer available as technician has gone home.has gone home.

Order changed to CT/CTAOrder changed to CT/CTA

CT/CTA read as cerebellar infarctCT/CTA read as cerebellar infarct– Likely vertebral dissectionLikely vertebral dissection

5:355:35

5:405:40

6:056:05

QUESTIONSQUESTIONS

Did this represent exceptional care, Did this represent exceptional care, standard care, or sub-standard care.standard care, or sub-standard care.

Would this patient have been better off if Would this patient have been better off if he had his stroke outside the hospital?he had his stroke outside the hospital?

Could this happen at your hospital?Could this happen at your hospital?

University of Colorado ExperienceUniversity of Colorado Experience

In the year prior to rolling out the In the year prior to rolling out the inpatient stroke alert systeminpatient stroke alert system– 6 inpatient CVAs and 1 TIA brought to the 6 inpatient CVAs and 1 TIA brought to the

attention of the stroke teamattention of the stroke team– 1 CVA received tPA (16%)1 CVA received tPA (16%)

In the year following In the year following – 43 inpatient stroke alerts ( 17 CVAs and 5 TIAs)43 inpatient stroke alerts ( 17 CVAs and 5 TIAs)– 4 received tPA (2 IV, 1 IA, 1 both)4 received tPA (2 IV, 1 IA, 1 both)– 24% lysis rate for symptoms from CVA24% lysis rate for symptoms from CVA

University of Colorado ExperienceUniversity of Colorado Experience

ED stroke alertsED stroke alerts

Time from ED triage Time from ED triage to CT scan for to CT scan for CVA/TIAsCVA/TIAs– 28 min28 min

Inpatient StrokesInpatient Strokes

Year prior to inpatient Year prior to inpatient stroke alert systemstroke alert system– 127 min127 min

Year following Year following inpatient stroke alert inpatient stroke alert systemsystem– 79 min79 min

Lessons LearnedLessons Learned

High quality stroke care requires more High quality stroke care requires more than smart and motivated caregivers ……than smart and motivated caregivers ……

It requires systems engineeringIt requires systems engineering

System Changes NeededSystem Changes Needed

Education of all staff Education of all staff on stroke symptomson stroke symptoms

Single alert numberSingle alert number

Mobilization of staffMobilization of staff

(rapid response team)(rapid response team)

Priority path for Priority path for imagingimaging

Specified stroke labsSpecified stroke labs

Core stroke team Core stroke team capable of delivering capable of delivering lytics or higher level lytics or higher level interventionintervention

Standardized post-Standardized post-stroke order setstroke order set

What do you call a group of people What do you call a group of people who take care of stroke patients?who take care of stroke patients?

If you guessed “Pace”….If you guessed “Pace”….

That’s uncharitable

What do you call a group of people What do you call a group of people who take care of stroke patients?who take care of stroke patients?ParamedicsParamedics

ED physiciansED physicians

HospitalistsHospitalists

IntensivistsIntensivists

NeurologistsNeurologists

NeurosurgeonsNeurosurgeons

PMNR physiciansPMNR physicians

NursesNurses

PharmacistsPharmacists

Physical TherapistsPhysical Therapists

Occupational Occupational TherapistsTherapists

Speech TherapistsSpeech Therapists

Interventional Interventional radiologistsradiologists

The Stroke Team

Clinical Feature Points

Age > 60 years 1

Blood pressure BP > 140/90 1

Clinical Deficits Unilateral WeaknessOR

2

Speech Impairment 1

Duration > 60 min 2

10-59 min 1

Diabetes Present 1

Maximum Score 7

ABCD2 SCORE

Predicted Risk of Stroke Predicted Risk of Stroke Following TIAFollowing TIA

ABCD2 ABCD2 ScoreScore

0-30-3 4-54-5 6-76-7

Risk Risk Stratification Stratification

Low Low Intermediate Intermediate High High

2-day Risk 2-day Risk 1%1% 4.1% 4.1% 8.1% 8.1%

Adapted from “Validation and Refinement of Scores to Predict Very Early Stroke Risk After Transient Ischaemic Attack”

7-day Risk 7-day Risk 1.2%1.2% 5.9% 5.9% 11.7% 11.7%

90-day Risk 90-day Risk 3.1%3.1% 9.8% 9.8% 17.8% 17.8%