Acute Stroke Protocols Modified- What s New in 2013

Transcription

1 Acute Stroke Protocols Modified- What s New in 2013 KUMAR RAJAMANI, MD, DM. Vascular Neurologist-MSN Associate Professor of Neurology WSU School of Medicine. Saturday, September 21, 2013 Crystal Mountain Resort and Spa

2 DISCLOSURES I have no relevant conflicts of interest to declare FDA has approved use of IV tpa up to 3 hours after symptom onset. I will discuss it s use outside that window. 2

3 INTRODUCTION Landmark NINDS tpa trial published FDA approves IV tpa for acute ischemic stroke SJMO first hospital in MI to be certified Primary Stroke Center Guidelines for Acute Stroke Treatment was published by the ASA Stroke Mortality drops to 4 th (from being 3 rd leading cause in the US ) Extended Time Window for IV tpa to 4.5 hours approved 2013 New Set of Guidelines issued by AHA/ASA 3

4 Changes in 2013 Guidelines compared to 2007 The changes are mostly evolutionary than revolutionary, suggesting a better understanding of different factors. - Edward Jauch 4

5 Quality Improvement Stroke Centers Establish primary and comprehensive stroke centers Establish acute stroke-ready hospitals Independent, external certification Quality improvement committee Bypass unequipped hospitals Telestroke capability 5

6 Emergency Evaluation and Treatment Organized Stroke Care Protocols Designated Acute Stroke Team : Including physicians, nurses, laboratory personnel, radiology personnel Rapid Neurological evaluation: Stroke Rating scales: NIHSS Laboratory investigations: CBC-including platelet count, Blood glucose, PT, INR, BUN, S.Creatinine, EKG, troponin 6

7 ED BASED CARE- GOALS Action Time Door to physician Door to stroke team Door to CT initiation Door to CT interpretation Door to drug 10 minutes 15 minutes 25 minutes 45 minutes 60 minutes 7

8 Emergency Evaluation and Lab Tests ALL Patients Blood glucose Oxygen saturation Serum electrolytes/renal function tests CBC including platelet count Troponins PT/INR/aPTT ECG Selected patients TT and/or ECT if patient is taking direct thrombin/xa inhibitors Hepatic function tests Toxicology screen/alcohol Pregnancy test Arterial blood gas tests (if hypoxia is suspected) Chest radiography (if lung disease is suspected) LP (if SAH is suspected and CT scan is negative for 8

9 Emergency Evaluation and Treatment Unchanged: Rapid evaluation and treatment Revised : Door to Needle time: < 60 minutes Only Blood Glucose ( finger stick acceptable) should precede administration of IV tpa!! 9

10 Emergency Evaluation and Treatment Other Revised from Previous Guidelines Baseline EKG: Baseline Troponin: Chest Xray: not shown to be useful. Recommended but should not delay tpa administration!! 10

11 Emergency Evaluation and Treatment Unless there is history of Bleeding disorder, or thrombocytopenia, Or patient is known to be on Heparin/Lovenox, taking Coumadin or one of the newer oral anticoagulants IV Tpa should not be withheld awaiting these laboratory results 11

12 Newer Anticoagulant Use DABIGATRAN RIVAROXABAN APIXABAN Mech of Action Direct Thrombin Inhibitor Factor Xa inhibitor Factor Xa inhibitor Elimination Mostly Renal Renal, Fecal, & Hepatic Renal, Fecal & hepatic Half Life hrs 5-9 hrs 12 hrs 12

13 EXCLUSION CRITERIA FOR IV tpa USE Significant head trauma or prior stroke in previous 3 months Symptoms suggest SAH Arterial puncture at noncompressible site in previous 7 days prior ICH Intracranial neoplasm, arteriovenous malformation, or aneurysm Blood glucose concentration <50 mg/dl Recent intracranial surgery Systolic >185 mm Hg or diastolic >110 mm Hg) Active internal bleeding Acute bleeding diathesis, Platelet count <100 K Heparin received resulting in abnormally elevated aptt anticoagulant use INR >1.7 or PT >15 seconds CT : hypodensity > 1/3 rd hemisphere 13

14 EXCLUSION CRITERIA HAVE BEEN NARROWED Relative Exclusion Criteria ( previously these were Absolute Exclusions!) Minor or rapidly improving stroke symptoms Pregnancy Seizure at onset Major surgery or serious trauma (within previous 14 days) Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days) Recent acute myocardial infarction (within previous 3 months) Recent experience suggests that under some circumstances with careful consideration and weighting of risk to benefit patients may receive fibrinolytic therapy despite 1 or more relative contraindications. Consider risk to benefit of IV rtpa administration carefully if any of these relative contraindications are present 14

15 Thrombolysis in hour window Relative Exclusion Criteria Aged >80 years Severe stroke (NIHSS>25) Taking an oral anticoagulant regardless of INR History of both diabetes and prior ischemic stroke 15

16 Emergency Evaluation Imaging Studies Symptoms resolved (TIA) or unresolved (Stroke?) 16

17 Symptoms Not Resolved ie Stroke Noncontrast CT or MRI prior to therapy IV fibrinolysis if ischemic changes present Possible intracranial vascular study Consider CT/MRI perfusion and diffusion imaging Large CT hypodensity withhold rtpa 17

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19 Early Ischemic Changes GIVE tpa tpa contraindicated 19

20 Hyperdense MCA sign

21 Progression of Infarct Core NEJM 2007:357;572

22 CTP image showing Penumbra

23 CTA/CTP These may be useful in some situations before proceeding interventional treatments The CTA/CTP if performed should not delay the administration of IV tpa!! 23

24 Symptoms Resolved - TIA MRI remains preferred over CT. Unchanged: In patients with suspected TIAs, noninvasive imaging of cervical vessels is indicated in 24 hours. Revised: In cases of known steno-occlusive disease, CT angiography or MR angiography of intracranial vasculature is recommended to assess for proximal intracranial stenosis and/or occlusion. Catheter angiography is necessary to confirm diagnosis and assess stenosis severity. 24

25 Thank You Questions? Kumar Rajamani MD,DM