Advances in Acute stroke Management
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1 Advances in Acute stroke Management Sandra Ripper-Brown, DNP Neuroscience Nurse Practitioner St. Mary s Medical Center WPB, FL Palm Beach County Nurse Practitioner Council Annual Conference APRNs: Agents of Change October 13, 2018
2 Objectives Upon Completion the attendee will: Recognize goal differences in management of ischemic and hemorrhagic stroke events Have increased knowledge of improved medical and mechanical treatments of acute ischemic stroke Understand advances in mechanical intervention methods in acute cerebral hemorrhage Become aware of potential access barriers to acute stroke management
3 Refreshing our memory Stroke: leading cause of severe disability; 3rd in death Advances: spurred by prevalence/impact of stroke Two types of stroke: Ischemic and Hemorrhagic Two subgroups of hemorrhagic: ICH and SAH
4 Goals! Ischemic Restore the flow Hemorrhagic Stop the flow
5 A little history: Ischemic Stroke Medical management: Symptoms/complications IV tpa 1996 Mechanical removal (embolectomy) 2015 International Stroke Conference, Nashville: embolectomy superior to tpa IV/IA tpa with embolectomy
6 Is it a stroke? Get a plain CT of the head!
7 Ischemic pathway? Normal CT Too late
8 Flow obstruction? CT: Dense R MCA CTA: L MCA Occlusion
9 CTP: Ischmeic Penumbra
10 Ischemic Stroke: Pharmaceutical (tpa) NIHSS Process LSN: hrs PTA Time window exclusions: 3-4.5H onset, AC, NIHSS > 25, DM + prior stroke Effective 1/3 patients Barriers Mimics, confounding presentation LSN clarification Poor historians Rx and PMH Public/EMS education Low rates of administration Remote area access
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14 Overcoming barriers Public education: FAST, 911 Establish CODE STROKE policy ED education: stroke clinics, CEU EMS & Stroke team: education, assessment tools, protocol development, hospital routing, CT/intervention participation, crew recognition, Stroke team support of ED staff in acute phase Teleneurology for remote locations
15 Embolectomy Process Symptom presentation (NIHSS), LSN <24h Administer tpa if time eligible CTA evidence of LVO Barriers LSN *does, allow for intervention for non-tpa eligible candidates) Geographical barriers Imaging availability CTP evidence of penumbra Rapid transfer to angio suite
16 Evolution of Embolectomy Merci Penumbra - aspiration
17 Evolution of Embolectomy: Stentreivers Device Function Solitaire Trevo Penumbra Emboshield
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19 Embolectomy: Before & After Digital Subtraction Arteriogram (DSA)
20 Post-embolectomy
21 Without intervention (MRI & MRA)
22 Without intervention (CT)
23 Overcoming Barriers Trials: MR CLEAN, ESCAPE, SWIFT PRIME standard of care Building stroke programs Comprehensive Stroke Certification Including CTA and CTP imaging in eligibility screening
24 A little History: Hemorrhagic Medical management: Symptoms/complications Surgical intervention: aneurysmal clipping Mechanical intervention - aneurysm (embolization) Mechanical intervention hematoma (evacuation) Mechanical intervention intraventricular (external ventricular drain EVD)
25 Hemorrhage: Stop Flow Subarachnoid Intraparenchymal
26 SAH: Securing the Process Aneurysm Barriers Image-confirmed presence of aneurysm (CT, CTA, MRI, MRA) Clipping Coiling Stent-support Coiling Neurosurgical availability (clipping) Interventional Neurology vs Interventional Radiology Training Geographic barriers Flow Diverting
27 Embolization IA access via femoral artery Cerebral arteriogram: determine size and location Device selection Embolize Closure 6 month, 12 month, 18 month follow-up
28 Aneurysm Clipping
29 Coiling Direct (narrow neck) Stent-assisted (wide neck)
30 Coiling: Before & After
31 Flow diversion
32 Pipeline Before & after
33 Intraventricular Hemorrhage
34 Intraventricular ICH w/ IVE SAH w/ IVE
35 IVH with EVD
36 EVD
37 IPH/ICH (hematoma)
38 Acute ICH Treatment Intervention Medical management Acute intervention for complications: IVE, functional/cognitive decline Craniotomy Minimal-invasive evacuation Barriers Access to neurosurgical services Geographic location Pending evidence-based guidelines Myriad complications of hospitalization
39 Craniotomy
40 Minimally Invasive Evacuation
41 Hematoma Evacuation Before After
42 SAH & ICH: Overcoming Barriers Dynamic research outcomes implementing best practice guidelines & education Tele-neurology: expedite transfers to treatment centers from remote areas Public education on preventive measures Recognizing opportunities for improved primary management of secondary prevention
43 And in conclusion Stroke s impact on healthcare demands ongoing innovation in medical technology and NP roles Changing face of stroke creates dynamic nature of evidence based practice Need continues for on-going community and health provider education Advanced Practice NPs: agents of change in world of stroke care
44 Thank you! Questions? Comments?
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