Stroke in the ED Dr. William Whiteley Scottish Senior Clinical Fellow University of Edinburgh Consultant Neurologist NHS Lothian
2016 RCP Guideline for Stroke RCP guidelines for acute ischaemic stroke How can we deliver therapy quickly? Can we avoid intracranial haemorrhage? What are this patient s values? RCP Guidelines for TIA and minor symptoms Can we make a reliable diagnosis?
Initial assesment Glucose Ischaemic stroke symptoms <6 h Ischaemic stroke symptoms >6 h ICH ROSIER Stroke physician CT brain imaging <1 hr CTA arch to aorta radiologist review aspirin immediately Reverse any anticoagulation (vitk, 4 factor) BP <185/110mmHg Reduce blood pressure <4.5 hr IV Alteplase Neurosurgery if: Hydrocephalus Posterior fossa <6 hr IA thrombectomy Antiplatelet >24 hrs <72 hr Decompressive hemicraniectomy Stroke unit
Effects of rt-pa on mrs 0-1 by time to treatment Early treatment better than later Benefit undetectable by 5 hrs Confidence interval still wide Emberson et al Lancet 2014
Doc 1 Nurse 1 or Doc 2 Introduce yourself, calm & kind Examine for focal deficit Time of onset: patient/witness Normal? physiological observations Book/warn CT Checklist & EHR: CI & prior CT: read in place Re-examine Resolved? Simple counselling - frame Deliver alteplase Must be <30 minutes. Aim for 15 --20 minutes Stand patient up More detailed history Re-assess in 15 minutes
4-7% risk of symptomatic intracranial haemorrhage after rt-pa
Licensed contra-indications to alteplase Things that may increase the risk of bleeding Prior ICH, AVM, aneurysm, brain tumour, recent surgery, delivery, bleeding diathesis, anticoagulants with abnormal clotting, pericarditis, endocarditis, pancreatitis, bleeding cancers, external heart massage, stroke <3 months Where risk and benefit needs some thought Rapidly improving, minor or severe strokes, very old, high glucose Things that increase risk of non-stroke diagnosis Symptoms of seizure at onset or suggestion of subarachnoid haemorrhage, low glucose Not sure Prior stroke and diabetes, high glucose, SBP > 185 or diastolic BP > 110 mm Hg, or aggressive management of BP
51 year-old man Sudden onset frontal headache and left sided weakness involving face at 21:00 No PMH or vascular risk factors OE GCS 14-E3 V5 M6- Drowsy but responding to commands No dysphasia, left lower facial weakness, unable to assess visual fields, left arm power 1/5, left leg power 3/5, loss of sensation down left side Atrial fibrillation
51 year-old man: progress Intravenous thrombolysis <1 hour The next day: GCS 14, dense left hemiplegia, dull headache, complete left sided sensory deficit, left hemianopia and gaze palsy
Malignant middle cerebral artery territory oedema Planned extracranial brain herniation post surgery intracranial pressure ischaemia Normalise intracranial pressure
End-of of-life decisions in patients with severe acute brain injury In treatment in patients with severe acute stroke [..] continuation of treatment often allows patients to live for months or years, but at the cost of being left in a state of disability that might be against their wishes [prior to stroke] Guerts. Lancet Neurol 2014
Possible transient ischaemic attack Aspirin 300mg followed by 75mg Immediate brain imaging if on anticoagulation Always look for asymptomatic problems hemianopia, inattention, dyspraxia If in AF, start anticoagulation Blood pressure? Statin? Carotid imaging within 24 hours If >7 days post symptoms,t2*mri to look for ICH Advise about driving Refer to TIA clinic to be seen <7 days
Why is rapid diagnosis important? FURTHER STROKE 14 Risk of stroke (%) 12 10 8 6 4 2 0 0 7 14 21 28 Days Higher risk if Age: older Blood pressure: higher Clinical features: weakness/speech Duration: longer Diabetes: present Imaging: positive
Doesn t look like a stroke but is? Persistent global amnesia Bilateral thalamic strokes Focal epilepsy Labyrinthopathy Glioma Peripheral nerve lesion Confusion/delirium Inattention/cognitive deficit Limb-shaking TIA Brainstem stroke Critical carotid stenosis Cortical stroke Bilateral occipital strokes Parietal stroke
Diagnosis Single episode of speech arrest due to glioblastoma multiforme of left posterior temporal lobe
Diagnosis Multiple territory cardio-embolic ischaemic strokes secondary to atrial myxoma
Migraine and migraine plus Rare probably over diagnosed - cause of acute hemiparesis Familial hemiplegic migraine Headache, fever, meningismus, hemiparesis quick onset & prolonged Dominantly inherited: CACNA1A -Ca ++ channel Headache and Neurological deficits with Lymphcytosis headache, deficits involving different neurovascular territories, and CSF lymphocytic pleocytosis. Cerebral vasoconstriction syndromes Thunderclap headache, transient focal neurological deficits (usually visual), sometimes persistent leading to stroke.
My diagnostic performance Survival free of stroke or MI Not TIA or stroke, or unlikely TIA or stroke definite or most likely P=0.0019 Days post presentation
Severe stroke How can we deliver therapy quickly? Practice, senior supervision, keep simple, focus on time Can we avoid intracranial haemorrhage with alteplase? No What are this patient s values? Is survival with severe disability worse than death? TIA Can we make a reliable diagnosis? Weakness, clear dysphasia yes; other symptoms more difficult
February 2019