Karl Meisel, MD MA Director of Stroke Clinic University of California San Francisco I have no financial disclosures 1
Hospital Management Thrombolytic and Thrombectomy Blood pressure Stroke in the Young Large vessel stroke Cardio-embolic stroke Antiplatelet Anticoagulation Prevention of complications Stroke Clinic Management issues Cryptogenic stroke Risk factor modification Post-Stroke Depression 1 in every 20 deaths in the US 20% increase in prevalence by 2030 3.4 million more people over the age of 18 57% of stroke mortality is outside a hospital 2
Age-adjusted death rates for stroke by sex and race/ethnicity, 2011. Dariush Mozaffarian et al. Circulation. 2015;131:e29-e322 Copyright American Heart Association, Inc. All rights reserved. IV rtpa is the standard therapy if < 3 hours NNT is 3 for improved outcome Every 15 minute reduction in DTN = 5% improved in hospital mortality < 1/3 of patients had DTN times < 60 minutes. 3
Normal/near normal = NNT 8.3 Improved = NNT 3.1 For 100 patients treated with tpa 32 benefit and 3 harmed 3 4.5 hrs (not FDA approved) but 16% more have good outcome Lancet 2004;363:768-74. 4
Blood Pressure < 185/110 Hemorrhage risk (ICH, SAH, AVM, Neoplasm) Bleeding diathesis (INR, heparin, platelets) Recent Surgery Hypoglycemia Head trauma or stroke in last 3 months > 1/3 hemispheric infarct on CT Minor Seizure Minor deficits MI within 3 months Pregnancy 5
Not FDA approved but is supported by guidelines Trial exclusion criteria Age >80 Baseline NIHSS >25 Any oral anticoagulant Previous stroke and diabetes Suggest some attempt at obtaining consent Recanalization Rate: ICA terminus 4.4% M1 32.3 % Basilar 4% 6
MR CLEAN stent retriever up to 6 hours 32.6% versus 19.1% independent; OR 1.67 ESCAPE trial stent retriever up to 12 hours 53% versus 29.3% independent; Ratio 1.8 EXTEND IA - 71% versus 40% SWIFT PRIME 60% vs 35% OR 2.75 NEJM. 2015; 372:11-20 NEJM. 2015; 372:1019-30 NEJM 2015; 372:1009-18 NEJM 2015; April 17 Epub ahead of print 7
Initial ED Evaluation within 10 minutes Notify stroke team within 15 minutes of arrival CT scan within 25 minutes Read on CT within 45 minutes IV tpa within 60 minutes Thrombectomy for proximal vessels in < 6 hrs Other studies: glucose, O2 sat, BMP, CBC, cardiac enzymes, INR/PT/PTT, EKG. Stroke. 2013;44:870-947 65.8% of the American population has access within 60 minutes to a primary stroke center. 63.1% had access to comprehensive stroke centers Triage directly to primary stroke centers is advised. Rural stroke patient 10 times less likely to receive tpa than urban primary stroke center. Neurology. 2015;84:1196-205 Telemed J E Health. 2012;18:230-237 8
Stroke Ambulances: Time to treatment is reduced by 41 minutes Drip and Ship agreements between hospitals Tele-neurology/stroke evaluation remotely Lancet Neurol. 2012;11:397-404 Analysis of 12 telestroke networks had 23%thrombolysis rate 10-fold increase from baseline AHA recommends telestroke if on-site stroke expertise is insufficient for 24/7 coverage Class I, Level A 18% lower risk of a poor outcome with telestroke. Stroke 2009;40:902-8. Neurology 2011;77:1590-8. 9
LOC: Responsiveness, Questions, Commands Eye Movement Visual fields Facial Palsy Motor Arm : left and right Motor Leg: left and right Ataxia Sensory Language Speech Extinction and inattention Minor is 1-4 Moderate 5-15 Moderate to severe 16-20 Severe 21-42 Stroke patient decompensates Decompressive craniotomy Class I, B NNT 2 mortality, NNT 4 to be ambulatory Advanced age and patient/family values may change this Evaluate for EVD 10
ICU for frequent Neuro and Vital Sign monitoring Every 15 minutes for 2 hours Every 30 minutes for 6 hours Every 1 hour until 24 hours post tpa Stop tpa if severe HA, worsening exam BP goal < 180/105 No heparin products, anti-platelets for 24 hours Obtain HCT or MRI in 12-24 hrs Avoid or delay invasive procedures (NG, Foley) NPO unless passes swallow screen Aspirin 325mg or 300mg rectal if no NG or NPO Permissive blood pressure < 220/120 for 48 hours Can consider ICU vs Medical/Stroke Unit with telemetry based on clinical scenario Lovenox for DVT prophylaxis NG if fails formal speech evaluation 11
PT/OT/Speech - Early mobilization Euthermia Euglycemia. Goal glucose 100-200 Cholesterol panel. Fasting glucose or A1C. Stroke education of risk factors and treatment Smoking cessation, diet and exercise Avoid Foleys or minimize use < 24 hours What is the etiology: Artery-to-artery embolism (carotid disease) Cardio-embolic (atrial fibrillation) Small vessel disease (diabetes, hypertension) Hypercoagulable Cryptogenic 12
Increasing proportion of ischemic stroke patients Etiology: dissections, cardioembolism, thrombophilias CT or MR angiogram of the neck vessels If TTE is negative then TEE with bubble study Lupus anticoagulant, anticardiolipin, HC, MTHFR, toxins Lumbar puncture in suspected vasculitis patients Carotid Ultrasound if anterior circulation, TCD for intracranial stenosis CT or MR angiogram head and neck Echocardiogram Telemetry 13
>70% stenosis or 50-69% stenosis on ipsilateral side of infarct Confirm ultrasound with CT or MR angiogram Cerebral angiogram if acute occlusion. If >70% stenosis confirmed or critical stenosis but not occlusion then endarterectomy within 2 weeks High risk of recurrent stroke WASID warfarin versus aspirin SAMMPRIS 20.9% vs 12.9% (stroke and death) VISSIT 36.2% vs 15.1% (stroke and TIA) EC/IC Bypass Study surgery vs aspirin 44% vs 23.7% NEJM 2005;352:1305. Lancet 2014;383:333-341. NEJM 1985;313:1191-1200. JAMA 2015;313:1240-1248 14
Hypertension: Permissive hypertension < 220/110 if no rtpa < 180/105 if rtpa given frequent measurements Lower by 15% - U shaped curve Avoid venodilators (nitro, hydralazine) Diuretic and ACE-I preferred 12 point reduction in BP reduces stroke by 37% Goal < 140/90, perhaps < 130 systolic for lacunar Stroke. 2013;44:870-947 Stroke. 2014;45:2160-236 Acutely atorvastatin 80mg Goal is LDL-C is < 100 Diabetic patient goal LDL-C is < 70 Follow up liver function in 6 weeks Each 10% LDL reduction reduced risk of stroke by 15.6% Stroke 2014;45:2160-236 NEJM 2006;355:549-59 15
% Coronary Surface Covered 5/22/2015 1% reduction in HbA1C decreased hazard ratio by 21% Reasonable goal of A1C < 7. 90 60 30 0 30 40 50 60 70 80 Age Plasma Cholesterol Level of 200 mg/dl (5.17 mmol/l) Grundy SM, JAMA 1986 Estimated 10-year stroke risk in adults 55 years of age according to levels of various risk factors (Framingham Heart Study). Dariush Mozaffarian et al. Circulation. 2015;131:e29-e322 Copyright American Heart Association, Inc. All rights reserved. 16
Aspirin (15% RR) - acutely 325mg daily Clopidogrel - 75mg daily Dipyridamole-aspirin twice daily Clopidogrel and dipyridamole-aspirin are superior to aspirin and non-inferior to each other CHANCE trial - clopidogrel and aspirin for 90 days NEJM 2013;369:12-19 At least 15% of ischemic stroke. Anti-coagulate about 1 2 weeks post large territory infarct. Consider sooner if small infarcts or mechanical heart valve. No heparin bridging required 17
Score 1 = > 95% sensitivity for predicting stroke Circulation.2012;126:860-865 Warfarin INR goal 2-3, only 60% are in range Dabigatran - 150mg twice daily Superior to warfarin in RE-LY study. Major bleeding same, but less intracranial bleeds Apixaban 5mg twice daily Superior to warfarin in ARISTOTLE study. Fewer major bleeding events and lower mortality Rivaroxaban- 20mg daily Non-inferior to warfarin in ROCKET-AF trial No difference in bleeding and less intracranial bleeds NEJM. 2009;361:1139-1151; NEJM. 2011:365:981-992; NEJM. 2011;365: 883-891 18
Warfarin Rheumatic heart disease Cardiac thrombus Thrombophilias Mechanical heart valves Dissection of vertebral or carotid artery LMWH Neoplasm related hypercoagability Pregnant women Avoid if MRI evidence of amyloid angiopathy Stroke education Medication education Smoking cessation Holter ideally 30 days Alert family to signs of decompensation and poststroke depression Rehab arrangements 19
1/3 of patients discontinued >1 medications within 1 year 2/3 of Medicare patients who had a stroke died or were rehospitalized within 1 year Never seen by a neurologist Communication lacking from the inpatient to rehabilitation to outpatient primary physician Stroke 2011;42:159-66. Neurology 2011;77:1182-1190 Cryptogenic stroke: 1/3 rd of ischemic strokes CRYSTAL AF study 12.4% vs 2% in 12 months TEE range of value 2-20% detect a lesion TCD with emboli detection Pulmonary shunting Occult neoplasm evaluation CADASIL, infection, vasculitis NEJM 2014;370:2478-86 Am Heart J 2014;168:706-12 20
PFO was not associated with increased risk Meta-analysis showed no benefit of closure Aortic Arch Atheroma - >4 mm Aortic Stenosis Mitral valve disease Myxoma and thrombus Stroke 2014;45:3352-9. Can J Cardiol 2014;30:1216-24 50 75% of stroke or TIA patients 7% had central sleep apnea Poor prediction with Epworth Sleepiness Scale Poorer outcomes with mortality, delirium,, functional status, depressed mood CPAP use NNT was 4.9 Stroke. 2014;45:2160-236. Eur Respir J 2012:39:906-912 21
About 1/3 rd of stroke patients suffer depression PTSD in 29.6% of patients after TIA Double the risk of suicide (male, young, severe) Higher Mortality 3.4 times for another event Increased cognitive impairments Stroke 2014;45:3360-6. Neurology 2015 April 1. Lancet Neurology 2011;10:123-30 22
Age - 60 = 1 Blood pressure = 1 Speech impaired = 1 Weakness = 2 10-59 minutes = 1 60 minutes = 2 Diabetes = 1 2 day stroke risk: 0-3 = 1% 4 5 = 4.1% 6-7 = 8.1 % Lancet 2007;369:283-292 23