Top 5 Big Things in Acute Stroke Care! Raymond W. Grams II, DO Vascular Neurology Stroke Medical Director DRMC, Intermountain Healthcare

Late Time Window Endovascular Trials 48.6% WITH intervention vs 13.1% NO intervention 73% relative reduction in disability

Pre-Hospital Stroke Scales Stroke Recognition Scales CPSS-Cincinnati Pre-Hospital Stroke Scale LAPSS- Los Angeles Pre-Hospital Stroke Screen Med PACS- Medic Pre-Hospital Assessment for Code Stroke OPSS- Ontario Pre-Hospital Stroke Screening Tool FAST- Face, Arm, Speech Test Stroke Severity Scales/Large Vessel Occlusion (LVO) C-STAT Cincinnati Stroke Triage Assessment Tool RACE- Rapid Arterial Occlusion Evaluation Scale LAMS- Los Angeles Motor Scale FAST-ED- Field Assessment Stroke Triage for Emergency Destination

Cincinnati Stroke Triage Assessment Tool (C-STAT) C-STAT Scoring 2 points Conjugate gaze deviation 1 point Incorrectly answers at least one question (patient age and current month) AND unable to perform at least one command (open and close eyes, open and close hand) 1 point Cannot hold arm up for 10 seconds (either right, left or both) Positive C-STAT 2 71% sensitivity 70% specificity for LVO Katz et al, Stroke 2015 McMullan et al, Prehosp Emerg Care 2017

Practice C-STAT C-STAT Scoring 2 points Conjugate gaze deviation 1 point Incorrectly answers at least one question (patient age and current month) AND unable to perform at least one command (open and close eyes, open and close hand) 1 point Cannot hold arm up for 10 seconds (either right, left or both) Positive C-STAT 2

Practice Case #1 80 yo woman calls 911 with the complaint of weakness. Cincinnati Pre-Hospital Stroke Scale is positive for left facial droop and left arm drift. She has a right gaze deviation She is able to state her age and current month correctly and follow both commands From your CPSS exam you note that her left arm drifts down to the bed before 10 seconds What is the C-Stat score?

Practice Case #2 90 yo man calls 911 with the complaint of weakness. Cincinnati Pre-Hospital Stroke Scale is positive for right facial droop. No gaze deviation He is unable to state his age and the current month, but can follow both commands From your CPSS evaluation the patient s arm did not drift downward What is the C-Stat score?

Practice Case #3 65 yo woman calls 911 with the complaint of weakness. Cincinnati Pre-Hospital Stroke Scale is positive for right facial droop and right arm weakness No gaze deviation She is unable to state her age but does state the correct month. She can open and close her eyes correctly but does not open or close her hand to your command or with pantomime From your CPSS evaluation the patient s arm does drift downward before 10 seconds What is the C-Stat score?

Head Position after ischemic stroke: Up or down?

AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic Stroke In nonhypoxic patients able to tolerate lying flat, a supine position is recommended patients at risk for airway obstruction or aspiration and those with suspected elevated ICP should have the head of bed elevated 15-30 degrees

18 patients (43 monitoring sessions), acute stroke day 1-6, complete or >2/3 MCA territory infarction MAP, CPP, ICP decreased with HOB elevation (MAP 90.0, CPP 77.0, ICP 13.0 at 0 degrees vs MAP 76.1, CPP 64.7, ICP 11.4 at 30 degrees) MCA MFV decreased with HOB elevation (72.8 cm/s at 0 degrees vs 49.9 cm/s at 30 degrees) Schwarz et al, Stroke 2001

Schwarz et al, Stroke 2001

In patients with large hemispheric stroke CPP was maximal in the horizontal position although ICP was usually at its highest point. If adequate CPP is considered more desirable than the absolute level of ICP, the horizontal position is optimal for these patients. Schwarz et al, Stroke 2001

20 patients, acute stroke <24 hrs, median NIHSS 14, persistent arterial occlusion within anterior circulation MCA MFV increased in all patients with lowering head position (max absolute increase 27 cm/s, avg 20%, range 5-96%) from baseline head position at 30 degrees Immediate neurologic improvement (avg 3 NIHSS motor points) occurred in 3 patients (15%) after lowering head position Wojner-Alexader et al, AAN 2005

Residual Flow Signals Predict Complete Recanalization in Stroke Patients Treated With TPA 75 patients consecutive patients treated with IV tpa with proximal MCA occlusion, median NIHSS 16, median bolus time 120 min, continuous TCD monitoring for 2 hours Complete recanalization in 25 (33%), partial in 23 (31%), no early recanalization in 27 (36%) within 2 hours after tpa bolus. Only 19% with absent residual flow signals on pretreatment had recanalization If pretreatment TCD showed residual flow, 41% had complete recanalization Labiche et al, Journal of Neuroimaging 2003

Major findings of HeadPost No differences in effects on disability outcome Positioning is safe no differential SAEs or PNA No clear benefit or harms in subgroups Time from onset of symptoms Initial stroke severity Age Region AIS vs. ICH/subtype of ischemic stroke

HeadPost Weaknesses: Low NIHSS Late Presentation Ischemic and hemorrhagic stroke patients allowed in study >10% within intervention arm did not stay flat Open design of study may have added potential bias and confounding

HeadPost Additional points to consider: Majority of patients outside of US and Europe where access to advanced imaging and interventions may be limited Lying the HOB flat is often a preliminary measure to assist with perfusion before tpa, blood pressure augmentation, anticoagulation, or endovascular intervention Persistent occlusions, that may have the greatest benefit of increased perfusion, may be unknown at time of presentation (Either no vessel imaging performed or M2/M3 occlusions not correctly identified) Do our current scales (NIHSS, mrs, etc) adequately detect preservation of cells when the human forebrain contains 22 billion neurons?

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