10/15/ ) Discuss changes in new guidelines for management of acute ischemic stroke patients.

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1 1) Discuss changes in new guidelines for management of acute ischemic stroke patients. Ischemic Stroke Care Erin Brinser, CRNP 2) Evaluate management techniques of complex stroke care. 3) Present current and comprehensive recommendations for the diagnosis and treatment of hemorrhage stroke. January 31, 2013, the AHA and ASA released new recommendations for the early management of acute stroke. These replace the 2007 guidelines and the subsequent 2009 update. Limit delays! Patients should be transported to the closest certified Primary or Comprehensive Stroke Center. This may involve air medical transport and hospital bypass. More than 900 Primary Stroke Centers in the US. Newer (Sept 2012) certification by Joint Commission and AHA/ASA. Recognizes additional resources in the infrastructure, staffing, and training at CSCs. Requires certain cerebrovascular case volumes, the adequate staffing of a neuro ICU, QI/research. 1

2 Abington Memorial *** Around 56 CSCs Lehigh Valley in the US today. Penn State Hershey HUP Thomas Jefferson Allegheny General UPMC Presby Establish primary and comprehensive stroke centers Independent, external certification QI committee Bypass unequipped hospitals Teleradiology when necessary Telestroke consultation Organized protocol Stroke rating scale Hematologic, coagulation, and biochemistry tests Only blood glucose must precede IV tpa Noncontrast CT or MRI is recommended prior to tpa administration to exclude hemorrhagic stroke and assess for s/s of ischemia If IA tpa or mechanical thrombectomy is being considered (which should NOT delay IV tpa) a noninvasive intracranial vascular study is recommended (CT/MRI perfusion and diffusion imaging) 2

3 Helps tease out etiology early Can see large vessel occlusions Will show viable brain (penumbra) delineated from infarct core Determines whether or not intra-arterial therapy is an option Ideally CTA/P should be done 45 minutes after IV TPA bolus Wake-up strokes can be treated with TPA despite ignorance of the time frame Suspected TIA noninvasive cervical vessel imaging Transient ischemic symptoms neuroimaging within 24 hours (MRI preferred) Steno-occlusive disease CTA or MRA of intracranial vasculature Lower BP to < 185/110 mmhg before IV tpa Maintain BP < 180/105 mmhg for at least 24 hours after IV tpa Treat hyperthermia Cardiac monitoring Oxygen and hypovolemia correction Pre-existing hypertension Restart medication Treat glucose abnormalities administration within 60 minutes of presentation to hospital ideal dose is 0.9 mg/kg (maximum dose 90 mg) BP should be lowered to less than 185/110 mmhg prior to administration - Japanese population/asian population perhaps requires less IV tpa (previous study demonstrated efficacy of 0.6 mg/kg of IV tpa) - ongoing multinational RCT in Australia, Asia, Europe, South America seeks to prove non-inferiority of low-dose tpa to standarddose - also assessing BP lowering post-stroke NCT

4 tpa eligibility criteria can be extended to 4.5 hours except for patients Over 80 years old On oral anticoagulants With a baseline NIHSS score >25 With imaging showing ischemic core > 1/3 MCA territory With a history of both stroke and DM tpa not recommended in taking direct thrombin inhibitors or direct factor Xa inhibitors Unless therapeutic drug monitoring (ECT, thrombin time, direct factor Xa activity) shows drug is ineffective/nontherapeutic. Unless patient hasn t taken agents for >2days. tpa can be considered in patients With rapidly improving symptoms With only mild stroke deficits (consider vocation) With major surgery within 3 mo With recent MI *** Weigh risk vs benefits, obviously!!! IV tpa should be administered to eligible patients even in IA intervention is being considered Select patients with MCA strokes of <6 hours duration who are not IV tpa candidates can benefit from IA fibrinolysis or mechanical thrombectomy Should only occur at qualified centers. Ultimate impact on patient outcomes yet undetermined. Stent retrievers (Solitaire FR and Trevo) are preferred to coil retrievers (Merci). Emergent intracranial angioplasty and/or shunting do not have proven usefulness. 4

5 1) SYNTHESIS (IV tpa vs IA tpa) NCT ) MR RESCUE too little too late doesn t work; onset of s/s to groin puncture was avg 6 hr 20 mins NCT cherry picking (The best patients were not randomized.) Not all patients got CTAs (So about 100 pts didn t even have a lesion.) Safety (Merci catheter caused a high SAH rate) 3) IMS III (started 2005, was stopped early) Effective only in severe stroke NCT NCT Merci catheter (2003) had a high rate of SAH (~20%). The overall complication rate has decreased from 16% to 7%. In the 1990s, IR technique involved dripping IA tpa over 3 hours, now a procedure takes less than 30 minutes. Time-sensitive Good for severe stroke M1 occlusions Carotid occlusions T and L occlusions Much ongoing research IV tpa vs. IV tpa + Stent retrievers (Trevo, Solitaire) In March 11, 1993, an article published stating angioplasty for STEMI is ineffective. Three years later, it became the standard of care. NCT

6 Urgent anticoagulation not recommended for AIS nor is it for non-ais conditions in the setting of mod-severe AIS. Anticoagulation within 24 hours of IV tpa administration is not recommended. Argatroban and other thrombin inhibitor usefulness has not be well established. Anticoagulating patients with severe stenosis of an ICA ipsilateral to an AIS has not proven useful. Clopidogrel s usefulness is not well established. The use of IV glycoprotein IIb/IIIa inhibitors is not recommended. (ie. ReoPro, Integrilin) Oral aspirin is recommended for most patients within hours of initial symptoms. Do not administer antiplatelet meds within 24 hours of IV tpa administration. Consider vasopressors only with symptomatic hypotension. Hyperbaric O2 is only recommended in cases of stroke d/t air embolization. No other potentially neuroprotective drugs are recommended. Induced hypothermia is not recommended. Urgent CEA has not proven efficacious in patients with large penumbras nor with unstable neurological status. 6

7 Studied since the 1950s Cardiac arrest, stroke Mechanisms of action Reduces cerebral metabolic rate of oxygen (CMRO2) approx. 5-6% for each 1 degree C reduction in brain temp Reduces damage from various excitotoxins, inflammation, free radicals, and apoptosis/necrosis. Decrease reperfusion injury and edema formation, and post-ischemic intracerebral hemorrhage Variables/Uncertainties Timing (induction, maintainence, rewarming) Target temperature Cooling technique/monitoring Complications (shivering, infections, metabolic derangements, arrhythmias, coagulopathy) Stroke care should be comprehensive and standardized. Swallowing assessments prior to intake/meds. Mobilize early and treat immobilized patients with SQ anticoagulants to prevent DVT. Nutritional supplements and prophylactic antibiotics not proven effective. NG feeding is preferred to PEG tube feeding until 2-3 weeks post-stroke. Antiepileptics for recurrent seizures but not for prophylaxis. Corticosteroids not recommended. Minimize brain edema/icp. Monitor closely and facilitate access to neurosurgery if necessary. Decompressive surgery if necessary. Malignant MCA stroke Neurosurgery consultation and consideration for hemicraniectomy Herniation Absolute emergency: Neurosurgical evaluation and urgent decompression Cerebellar stroke If stroke is of significant size there is a high risk of compressing the 4 th ventricle and Neurosurgery is consulted for consideration of craneictomy Hemorrhagic Conversion Happens in 2-44% of strokes (up to 70% in pathology cases) Depending on size & symptoms May need to reverse of coagluopathy anti-thrombotics may need to be held, May need Neurosurgical intervention Stringent BP goals, typically want SBP<150 7

8 All of the previous situations have one thing in common Cerebral Edema Combination of cytotoxic and vasogenic edema Medical Management of Cerebral Edema Hyperventilation Goal PCO Great option in an emergency, short term use only Mannitol g/kg bolus Great option in an emergency Hypertonic Saline Goal Na+ level Better option for long term administration 23.4% makes for effective emergency therapy In managing cerebral edema associated with ischemic stroke, we tend to favor 3% saline as our mainstay This requires PICC or central line for administration Should be done early, IV tpa is not a contraindication to PICC placement Start low rate (~15cc/hr) and check Serum Na+ q6h and increase rate as needed to achieve goal level ( ) Patients may suffer hyperchloremic acidosis and sodium bicarb may be needed to buffer Patient s receiving hypertonic saline usually require an additional meq of K+ per liter of infusion Central pontine myelinolysis (CPM) can occur if serum sodium rises to quickly CPM has never been reported after use of hypertonic saline, nor reported when initial sodium is in the normonatremic range Serum Osmolality should be kept Once the OSM exceeds 320 with mannitol renal failure can develop Rebound intracranial hypertension Prolonged administration of any osmotic agent may lead to increased cerebral edema by crossing a damaged blood-brain barrier (BBB) Cerebral edema peak is 3-5 days postischemia We tend to treat with hypertonic saline for about one week, sometimes longer if the intravascular osmotic pressure is also benefiting our MAP goals The AHA s national stroke registry and quality improvement program. Initiated in >1900 hospitals, >2 million pts recorded. Since GWTG-Stroke, more eligible pts are receiving appropriate stroke intervention and care. 8