Stroke Update GIM SpR Teaching Dr Amit Mistri Consultant in Stroke Medicine

Transcription

1 Stroke Update GIM SpR Teaching Dr Amit Mistri Consultant in Stroke Medicine

2 Learning objectives This session aims to improve knowledge on: GIM SpR as the Stroke oncall SpR ED process & responsibilities GIM SpR role(s) Hyperacute interventions in acute stroke Thrombolysis Thrombectomy Medications post stroke Risk factor control in stroke Thresholds and targets AF management for stroke prevention Objective estimation of risk General medical requirements

3 ED presentation 60 year old gentleman Witnessed onset of right side Pre-alerted as FAST + by EMAS RAP call from ED to alert the Stroke team Hypertensive on Ramipril

4 Questions Who has primary responsibility for this patient? What is the role for ED? What is the role for the GIM SpR (holding the Stroke bleep)? What is the role of the Stroke Consultant on call?

5 Responsibility All FAST + pre-alerts automatically fall under the remit of the Stroke Team (irrespective of initial or eventual diagnosis) The Stroke team (GIM SpR out of hours) will assess, diagnose, arrange initial investigation and establish where the patient needs to go There is no role for ED, unless critically unwell requiring resuscitation etc (uncommon)

6 FAST test PPV 89% NPV 73%

7 Paramedic acute stroke FAST + Acute Stroke Not Acute stroke Major disabling Minor nondisabling TIA Other medical Other nonsinister Stroke Unit TIA clinic TIA clinic AMU Discharge +/- follow up

8 Minor stroke?

9 ED strokes ED recognise an acute stroke ROSIER tool recommended Extension of FAST tool ROSIER + picks up vast majority of acute strokes If ROSIER - & clinical suspicion persists, then Reg2Reg discussion

10 ROSIER PPV 90% NPV 88%

11 Click picture to open full ED Pathway Stroke ED assessment proforma for adults

12 Stroke ED assessment proforma for adults

13 ED acute stroke ROSIER + Acute Stroke Not Acute stroke Major disabling Minor nondisabling TIA Other medical Other nonsinister Stroke Unit TIA clinic TIA clinic AMU Discharge +/- follow up

14 GIM SpR considerations Is it a stroke? Is medical stabilisation required? Is there an indication for urgent CT scan? Is thrombolysis a possibility? Is thrombectomy (clot extraction) a possibility? Is there a reason to not go to ASU?

15 Is it a stroke? Focal neurological deficit!! OCSP classification NIHSS neurological assessment

16 OCSP Aetiology Clinical Presentation Relevance TACS Proximal Contralateral hemiparesis High mortality total Stroke Patient anterior Paramedic 0cclusion (ICA or ED (+/- hemihypoaesthesia) ASU OP Clinic circulation stroke Rehab. MCA), large Contralateral heminaopia 20% volume infarct Higher cerebral Superficial + dysfunction (cortical signs: deep territories dysphasia, dyspraxia, inattention) TIA clinic PACS partial anterior circulation stroke 35% LACS lacunar stroke 20% POCS posterior circulation stroke 25% Occlusion of MCA branch Restricted infarct Single perforating artery Basal ganglia/pons 2 of above 3 OR Restricted motor deficit (face OR arm OR leg only) OR isolated cortical signs Pure motor, pure sensory, sensorimotor, ataxic hemiparesis Brainstem, cerebellar or occipital involvement High early recurrence rate Silent, underdiagnosed Complex presentation Thrombosis Bamford et al Classification and natural history of clinically identifiable subtypes of cerebral infarction Lancet 337; 8756: 1521

17 OCSP based prognostic estimate Prognosis more favourable than other clinical sub-types: 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% All ischaemic stroke 1 year outcome based on clinical subtype TACS PACS LACS POCS Independent Dependent Dead

18 Stroke mimics Things that look like a stroke Brain problems tumour, multiple sclerosis, traumatic bleeds outside the brain Spinal cord problems tumour, infection, trauma Peripheral nerve problems diabetic nerve damage Other neurological conditions migraine with stroke-like presentation, Bells Palsy, Transient memory loss etc Functional neurological syndrome looks like a stroke, but specialists can diagnose using examination, brain scan and symptom progression. Metabolic problems changes in blood levels of glucose, sodium etc

19 Is medical stabilisation required? Resp distress Fast AF Sepsis ACS

20 Next-on-table CT scan Neurological deficit onset within previous 4 hours Indication for thrombolysis/thrombectomy or early anticoagulation treatment On anticoagulant medication (e.g. VKA; NOAC/DOAC or heparin) Drowsiness GCS 13 and/or NIHSS 1a 1 Known bleeding diathesis Unexplained progressive / fluctuating symptoms after onset Severe headache at onset Papilloedema, neck stiffness or fever

21 What a scan is not for? NOT to rule out infarct ~80% of early scans are normal NOT prognostic Clinical assessment OCSP far better at prognosis Adjunctive value if obvious bleed or major infarct Should GIM SpRs interpret CT Brains? Radiology SpR available 24-7 Consultant can see image at home if needed Primer on Brain imaging in subsequent talk

22 Is thrombolysis a possibility? SUSPECTED STROKE Not for lysis Uncertain For lysis Standard management Ask Consultant Ask Consultant TIME IS BRAIN earlier presentation does not mean you have more time, it means that you have more potential to limit brain damage

23 Practical issues Cannula & bloods needed (JD) Bed needed (Stroke Sp N) Blood results not necessarily required Call Consultant for final lysis decision Weight based dosing - patient should be weighed on entering ED, if not use prior known weight or estimated weight (for bolus) Alteplase dosing chart available Bolus without delay (ideally in ED, after CT & Cons approval) 1h follow up infusion on ASU

24 6.3 Intravenous thrombolysis Robust UHL Guidelines

25 6.3.2 Exclusion criteria (1)

26 6.3.2 Exclusion criteria (2)

27 Thrombolysis consent Verbal, but documented - Patient or proxy or in best interests Brain scan shows no bleeding, and the clinical presentation suggests a clot causing blockage We recommend medication to try and dissolve this clot and minimise brain damage and associated disability This treatment can have side effects For every 20 people treated 6 are less disabled 13 are unchanged with respect to disability 1 is worse off because of a major bleeding complication

28 IP strokes Consistent evidence of poorer management & missed thrombolysis opportunities More likely to have contraindication to lysis e.g. on full dose heparin, recent operation etc PROCESS Other hospital > blue light to LRI ED (for CTH-RAP team) (unless over-riding clinical care need e.g. post surgical) LRI wards > avoid CT delays

29 Which statements are true? Once thrombolysed BP criteria are relaxed Respiratory distress is almost always due to anaphylaxis Anaphylaxis is more likely because this patient is on an ACE inhibitor Tongue swelling without rash/wheeze indicates early anaphylaxis Brain bleeding occurs in ~5%

30 Post thrombolysis care Bleed risk goes down with time Standard ASU protocol for monitoring Keep SBP<180 If neurological deterioration (GCS, NIH) Medical Rx cause Neurological repeat CTH Stop infusion? Is reversal required?

31 What is thrombectomy? Mechanical Thrombectomy (MT) or clot extraction Potent effect: NNT ~ 5 to improve outcome Not universally available, at present DoH commitment to fund this!!! Available in Nottingham / Birmingham ad hoc individual patient basis during working hours Pre-requisites Must involve Stroke Consultant Needs CT Angio with proximal MCA occlusion <6h from onset

32 Not for ASU patient Indication for neurosurgery if agreed, ideally direct to QMC may need interim ITU or Stroke Bed Other over-riding clinical need Ventilation in ITU or NIV in ACB Multi-system disease in ITU Clear indication for surgical intervention Acute cardiac condition requiring GH input

33 5 days later Medically stable, EWS 0 Weakness minimal, and mobilising on ward ECG sinus, pulse regular Had a Carotid Doppler undertaken

34 5 days later. Management plan which statements are true? Significant carotid stenosis is narrowing >70% Echocardiogram is recommended for all patients Vascular surgeons are unlikely to intervene after stroke High alcohol intake is not a risk factor for ischaemic stroke An ECG is frequently missed out Prophylactic heparin should be used for all patients to prevent VTE

35 25 days later. Mobilising independently Independent with ADLs BP well controlled No evidence of AF Aiming to go home with wife

36 25 days later. Management plan which statements are true? The 3 key groups of medications required are Antithrombotics, Antihypertensives and Antihyperlipidaemics Driving: patient can return to driving on day 30 Patients can be provided therapy at home A common cause of recurrent stroke is medication noncompliance There should be a low threshold for undertaking prolonged cardiac monitoring

37 Primary prevention >10% 10 year CV risk Aggressive therapy/targets - not generally advised Antiplatelet Aspirin lowdose no longer advised Antihypertensive NICE/BHS optimal target <140/85 Lipid modifying agent Targets TC<4.0, LDL<2.0 A/C for AF (CHADSVaSC) QOF: BP<150/90 QOF: TC<5.0

38 Secondary prevention No CV risk calculation high risk by definition Aggressive therapy/targets advised Antiplatelet Clopidogrel Aspirin+Dipyrid. Aspirin A/C for AF Antihypertensive NICE/BHS optimal target with TOD <130/80 NICE age>75: <140/90 QOF: BP<150/90 Lipid modifying agent Targets TC<4.0, LDL<2.0 QOF: TC<5.0 RCP Clinical Guidelines for Stroke 4 th Edition

39 Stroke mimics Things that look like a stroke Brain problems tumour, multiple sclerosis, traumatic bleeds outside the brain Spinal cord problems tumour, infection, trauma Peripheral nerve problems diabetic nerve damage Other neurological conditions decompensation of previous stroke deficit; migraine with stroke-like presentation, Bells Palsy, transient memory loss etc Functional neurological syndrome looks like a stroke, but clear discrepancy between objective and functional assessments, Hoover s sign + Metabolic problems changes in blood levels of glucose, sodium etc

40 Outpatient No recurrence of neurological symptoms Virtually complete recovery Taking Clopidogrel, Amlodipine 10, Atorva 40 Can he drive? Can he drink? Exercise recommendations?

41 Co-Chair of Anticoagulation Task & Finish Group AF & ANTICOAGULATION

42 AF indicates a preventable catastrophe Do a risk assessment promptly CHADSVASC annual rate of embolic stroke HASBLED annual rate of major bleeding (on A/C) Prior bleeding/predisposition to bleeding Aim to identify those that will not benefit Embolic risk too low (CHADSVASC 0, & 1 in women) Bleeding risk permanently high (irremediable structural lesion) if remediable, then r/v anticoagulation again Terminal stage of life?! Ideally same day ECG & A/C plan Specialist opinion if needed

43 Objective estimation of risk CHA2DS2VASc Score can only go up HAS-BLED Modifiable i.e. score can go down (e.g. if SBP treated to <160) chadsvasc.org

44 What A/C are available? Apixaban Dabigatran Edoxaban Rivaroxaban Warfarin All are GREEN for ATRIAL FIBRILLATION & STROKE PREVENTION <Primary & Secondary care> SHARED CARE AGREEMENT for VENOUS THROMBO-EMBOLISM <Secondary care initiated>

45 DOAC specific issues DO NOT USE ECHO for AF With metallic valves With mitral stenosis CrCl<30 Bleeding that contraindicates warfarin! Poor medication compliance Not routinely required if no murmur If requesting Echo, do not delay anticoagulation initiation Review Echo results (in case DOAC contraindicated)

46 DOAC monitoring Frequency of review in line with CKD guidance CrCl>60 CrCl<~60 CrCl<~45 12 monthly 6 monthly 3 monthly A Adherence assessment Content of review Thrombosis Canada Ann Intern Med 2015; 163: B C D E F Bleeding screen CrCl calculation Drug interactions check (BNF) Examination: BP Final assessment (continue, change dose or A/C, stop) Follow up DON T USE LOW DOSE Apix/Riva/Edox WITH THE INTENTION TO REDUCE BLEEDING RISK BECAUSE YOU DON T GET STROKE PREVENTION, IF DOSE REDUCED INAPPROPRIATELY

47 A/C related bleeds Life threatening, high mortality In AF populations, brain infarcts (not anticoagulated) are 5-10 times commoner than ICH (with A/C for AF) Hypertension management Aim for SBP<140 in all ICH inpatients Longer term aim for good BP control SBP< Management Local measures Resuscitation Antidotes now available on ED shop floor, soon to be measured as a Door-To-Needle metric

48 UHL Policy - DOACs

49 ADMISSION AND DISCHARGE OF PATIENTS ON ANTICOAGULATION PATIENT ADMITTED TO UHL WITHIN 24 HOURS OF ADMISSION, WARD SENDS REFERRAL TO ANTI-COAG IN-REACH TEAM FOR SUPPORT (WHERE CLINICALLY APPROPRIATE) COMPLEX PATIENTS TO REMAIN UNDER CARE OF UHL PATIENT RECIEVES ANTI-COAG MANAGEMENT PLAN (WARDS SUPPORTED BY IN-REACH TEAM AS CLINICALLY APPROPRIATE) NEW DISCHARGE LETTER/TEMPLATE SENT TO PRACTICE VIA ICE NON-COMPLEX PATIENT DISCHARGED TO PRIMARY CARE UHL TO DOSE FOR 4 WORKING DAYS EXCEPTIONS: SHORT STAY ADMISSIONS < 24 HOURS UNSTABLE INRs NOT DISCHARGED OVER WEEKEND PRIMARY CARE TO TAKE OVER PATIENT CARE AT DISCHARGE (DOSED FOR 4 WORKING DAYS) ANTI-COAG IN-REACH TEAM SUPPORT HELPLINE TEL: XXXXXXXXXXXXXXXXXX (WILL RESPOND IN XXXXXX) ADVICE AND GUIDANCE (NON URGENT) TEL: XXXXXXXXXXXXXXXXXXX CONSULTANT CONNECT (URGENT) TEL: XXXXXXXXXXXXXX IF PATIENT BECOMES COMPLEX ROUTINE REFERRAL ON CALL CONSULTANT HAEMATOLOGY TEAM TEL: XXXXXXXXXXXXX

50 SUPPORTING INFORMATION

51 NEUROLOGICAL 1. Brain oedema /swelling 10-20% MCA strokes 17-54% cerebellar 2. Secondary bleeding 30-40% 3. Recurrent stroke 1w 10%; 1m 2-3% Annual 5% 4. Seizures / fits Early 2-23%; late 3-67% 5. Delirium 13-48% 6. Central poststroke pain 7. Headache Sentinel 43-60% Onset 25-30% After 14-27% 8. Sleep disorders 10-50% MEDICAL 1. Infection 2. VTE (HAT) 3. Pressure Ulcers 4. Falls 5. Musculoskeletal Joint dislocations, pain PSYCHOSOCIAL 1. Psychological issues 2. Dignity

52 InSITE Stroke Services UHL Guidelines for Stroke & TIA Stroke ED Assessment Proforma for adults Clinical Medicine Expert recommendations NICE Guidelines for Acute Stroke & TIA RCP Guidelines for Stroke (more on longer term management) NICE Guidelines for AF