Stroke: The First Critical Hour Alina Candal, RN, PCC, MICN Kevin Andruss, MD, FACEP
Disclosures We have no actual or potential conflicts of interest in relation to this presentation.
Objectives Discuss regional stroke systems of care Discuss prehospital stroke triage to determine appropriate Stroke Center destination Discuss the acute management of stroke in the Emergency Department Review cases
Patient #1 81yr old female in moderate distress C/C: ALOC with Provider Impression of stroke VS: BP: 180/130, HR: 60, RR 16, 02 sat: 99% on room air BS 123 GCS: 4-1-6 LKWT was 30 min + mlapss facial droop, no grip on right, right arm rapid drift LAMS 5 MAR and PSC: Queen of the Valley CSC: PIH Health Whittier
Patient #1 What is mlapss? What is LAMS? Why did they bypass the closest hospital and primary stroke center to come to PIH Whittier?
Stroke Systems of Care Tiered Stroke System in LA County & surrounding area 50 Stroke Centers 32 Primary Stroke Centers (PSC) 18 Comprehensive Stroke Centers (CSC+TSC)
Primary Stroke Center A 911 receiving hospital that has met the standards of a Center for Medicaid & Medicare Services (CMS) approved accreditation body Acute Stroke Team available 24/7 Stroke Unit designated beds Neurology consult available 24/7 Neurosurgery available within 2 hours Treatments: IV thrombolytics and medical management of stroke
Thrombectomy-Capable Stroke Center In addition to PSC requirements Advanced imaging (CTA, CTP, MRI) available 24/7 Dedicated neuro intensive care beds available 24/7 Treatments: IV thrombolytics, mechanical thrombectomy, Intraarterial thrombolytics
Comprehensive Stroke Center In addition to PSC/TSC requirements Acute Stroke Team available 24/7 On-site Neurointensivist coverage 24/7 Neurology, Neuroradiology, Neurointensivist, Neurosurgery available 24/7 Treatments: IV thrombolytics, endovascular therapy (mechanical thrombectomy, IA thrombolytics), clipping/coiling of aneurysms, stenting of carotid arteries, carotid endarterectomy
Prehospital Stroke Screen - mlapss Modified Los Angeles Prehospital Stroke Screen (mlapss) on patients exhibiting local neurologic signs The mlapss is positive if all of the following criteria are met: 1. Symptom duration less than 6 hours 2. No history of seizures or epilepsy 3. Age 40 years or older 4. At baseline, patient is not wheelchair bound or bedridden 5. Blood glucose between 60 and 400 mg/dl 6. Obvious asymmetry-unilateral weakness with any of the following motor exams: a) Facial Smile/Grimace b) Grip c) Arm Strength If mlapss is positive Los Angeles Motor Score (LAMS)
Prehospital Stroke Screen - LAMS Calculate Los Angeles Motor Score (LAMS) from the mlapss motor items: 1. Facial Droop a) Absent = 0 b) Present = 1 2. Arm drift a) Absent = 0 b) Drifts down = 1 c) Falls rapidly = 2 3. Grip strength a) Normal = 0 b) Weak grip = 1 c) No grip = 2
Patient Destination Determined by prehospital screening exam: mlapss negative Transport to closest receiving hospital mlapss positive Transport to closest Stroke Center mlapss positive and LAMS 4 Transport to Comprehensive Stroke Center (CSC/TSC)
Time is Brain Every minute stroke goes untreated: 1.9 million neurons, 14 billions synapses and 7.5 miles of myelinated fibers are destroyed Benefit of IV thrombolysis and mechanical thrombectomy decreases in a continuous fashion over time
Prehospital Stroke Alert Upon notification of a stroke patient en route to PIH, a Prehospital Stroke Alert will be activated from the field. 1. Radio call notifies MICN suspected stroke en route, MICN activates Stroke Alert 2. Hospital operator announces overhead "Stroke Alert ETA X Minutes 3. Stroke team prepares for the rapid workup and treatment of stroke patient
Stroke Team Rapid workup and treatment of stroke patient Physician Nurses Pharmacist CT technician Phlebotomist EMT Transport technicians ED unit clerk
ED Workup History and physical exam Resuscitate and manage airway as needed Verify Last Known Well Time Patient, paramedics, family, etc. Order required imaging for suspected large vessel occlusion: NIHSS 6 or LAMS 4 Triple Scan CT Angiography head and neck, CT Perfusion brain Triple Scan obtained with non-con Head CT Screen for kidney disease
ED Management Review lab, EKG results, CT results Determine treatment based on stroke subtype Ischemic stroke tpa eligible? Large Vessel Occlusion? Intracerebral hemorrhage Subarachnoid hemorrhage
Ischemic Stroke
Acute Ischemic Stroke IV Thrombolytics Recombinant tissue-type plasminogen activator (rtpa) Activated Plasmin breaks up meshwork of fibrin that polymerized to form clot Recanalized vessel perfuse ischemic penumbra
Acute Ischemic Stroke Determine tpa eligibility tpa Inclusion/Exclusion Criteria checklist Consult Neurology Consent patient/family Administer tpa Goal door to tpa time <45 minutes
Large Vessel Occlusion Non-contrast CT Head Dense vessel sign CT Angiography Head and Neck Identify clot in large vessel CT Perfusion Core infarct: dead brain tissue Ischemic penumbra: salvageable ischemic brain tissue Large vessel clot + salvageable brain tissue mechanical thrombectomy
Mechanical Thrombectomy Five trials published in 2015: MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA, REVASCAT Large Vessel Occlusion: Mechanical thrombectomy superior to standard treatment with IV tpa alone within 6 hours of symptom onset Two trials published in 2018: DAWN, DEFUSE 3 Mechanical thrombectomy effective up to 24 hours from last known well time Clinical deficit disproportionately severe compared to volume of infarct on imaging
Hemorrhagic Stroke
Hemorrhagic Stroke - ICH Intracerebral Hemorrhage (ICH) Blood Pressure Management Lower SBP to 140mmHg Reversal of Anticoagulation Neurosurgical Consultation ICP monitoring Hematoma evacuation No evidence to support Seizure prophylaxis Platelet transfusions
Hemorrhagic Stroke - SAH Subarachnoid Hemorrhage Blood Pressure Management Lower SBP to < 160mmHg Reversal of Anticoagulation Neurosurgical consultation ICP monitoring CT Angiography Interventional Radiology, Neurology consultation Controversial: Seizure prophylaxis Antifibrinolytic therapy
Patient #2 - Presentation 63yr old female from home in moderate distress C/C: of CVA with a syncopal episode for 30 seconds Sitting in a chair with right facial droop, weak right grip and right arm drift. GCS: 4-5-6 VS: BP: 162/115, HR: 88, RR: 16, 02sat: 99% on room air BS 115 + mlapss, LAMS: 5 MAR: Whittier Hospital Medical Center CSC: PIH Health Whittier
Patient #2 - Results Patient presents to ED with right hemiplegia, aphasia NIHSS 11 CT head: dense left MCA sign LKWT confirmed, patient consented, tpa administered by emergency physician CTA Head/Neck: embolic occlusion at distal M1 CT Perfusion: large ischemic penumbra left MCA distribution, small core Neurology and Interventional Radiology consulted
Patient #2 - Outcome ED Interventional Radiology Endovascular Mechanical Thrombectomy successful NIHSS 1 after procedure Discharged HD #4 with minimal deficit mrs 0 at discharge
Thank you!