Rural management of stroke Dennis W. Dietrich, MD Benefis Healthcare Stroke Center Medical Director Disclosures Research funding by NIH, Merck, Lilly Prehospital care • The basics have not changed: – Stroke education – Calling 911 – Prehospital assessment – Rapid transport to a facility that can provide stroke care – Prehospital notification – Interhospital transfers for acute stroke care Acute Stroke‐Ready Hospital Written emergency stroke care protocols z A stroke “champion” to over see stroke policies and procedures (may be clinical staff member or designee of administration z Ability to perform emergency brain imaging (eg CT) z Ability to conduct emergency lab tests z Maintenance of a stroke patient log z Emergency evaluation and diagnosis of stroke z The basics: – An organized protocol – Rather than time of onset— “time last neurologically normal” – Stroke and TIA rating scales: NIHSS, ABCD2 – CT (or MRI) required for qualification for tPA – Only blood glucose must proceed tPA (new) – Goal is for treatment within 60 minutes of arrival NIH Stroke Scale (NIHSS) z YouTube videos: z NIH Stroke Scale Training Part 2 Basic Instruction** z NIH Stroke Scale Training Part 3 Demo Patient z Total of 8 different videos available for viewing z For NIHSS certification go to: z http://learn.heart.org/ihtml/application/ student/interface.heart2/nihss.html Rating scales ABCD2 score for TIA to predict stroke risk z Age (≥60 years, 1 point) z Blood pressure at presentation (>140/90, 1 point) z z Clinical features (unilateral weakness, 2 points or speech disturbance without weakness, 1 point Duration of symptoms (10‐59 min 1 pt, >60 min 2 points) z Diabetes (if history of DM, 1 point) z Total range is from 0 (low risk) to 7 (high risk) ABCD2 score and stroke risk Emergency evaluation‐other tests z Labs: z Chemistries, glucose*, CBC, PT/INR, PTT, O2 saturation, troponin z ECG z Cardiac monitor z Serial vitals, BP q 15 minutes if potential tPA candidate TIA Traditional Definition z z z Confusion about what is a TIA Original definition was a sudden focal neurological deficit of vascular origin confined to an area perfused by a specific artery, lasting less than 24 hours. According to Levy, in the NINDS study placebo arm, if the TIA did not resolve within 1 hour or rapidly improve over 3 hours, less than 2% resolved by 24 hours. TIA New Definition z Albers proposed definition of TIA – “a brief episode of neurologic dysfunction caused by focal brain a retinal ischemia with clinical symptoms typically lasting less than one hour and without evidence of acute infarction.” – Thus, if neurologic symptoms last more than one hour it should be considered a possible or likely stroke and treated appropriately. Management of TIAs According to the AHA, NSA, and ACEP, patients with symptoms of a TIA should: z Receive urgent evaluation z Have a history, physical, and ECG z z z Have brain imaging, preferably MRI including DWI if available, otherwise CT within 24 hours Have prompt or urgent evaluation for carotid stenosis by ultrasound, and CTA or MRA when indicated If the appropriate studies are not available, transfer should be considered, especially for patients with higher risk TIAs Case study 1 z z z 78 year old female with vision disturbance affecting both eyes, described a sense of double or even triple vision lasting 90 min, presented on Fri at 3:10 pm PMH: positive only for tx for hypothyroidism Exam normal except BP 183/85, Labs showed LDL 147, total chol 225, HDL 65 z Diagnosis TIA, HTN z It is now 5:30 pm on Friday Case study 1 cont. z z z Evening of admission at 03:30 noted difficulty with speech, right sided weakness and numbness and returned to ED at 09:30 CT was again negative Subsequent MRI showed an acute left midbrain and upper pons infarction and MRA showed 1 cm occlusion of the basilar artery with distal reconstitution and incidental 6 mm L CMA aneurysm MRI‐DWI of Case 1 TIA and stroke z z z MRI‐DWI is more sensitive than CT in identifying stroke in patients with TIA symptoms (clinically diagnosed) Pooled reports from 19 studies on 1117 patients show an aggregate rate of 39% with DWI positive lesion, ranging from 25‐67% There is also an increased risk of subsequent stroke in TIA patients with DWI lesions Updated guidelines z z z z Previous guidelines were published in 2007 and 2009 They were updated in 2013 in this publication: Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals by E. Jauch, et al. Stroke. 2013;44:870‐947. Accessed from montanastroke.org under the subheading “guidelines” See supplementary sheets for complete guidelines The Importance of Time in early t‐PA Stroke Trials Hacke, W., G. Donnan, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768-74. tPA Time to Administration vs. Improved Outcome Odds of a favorable 3‐month outcome increased as onset to treatment decreased (p=0.005) z Odds were 2.8 (95% CI 1.8‐4.5) for 0‐90 min, 1.6 (1.1‐2.2) for 91‐180 min, 1.4 (1.1‐1.9) for 181‐ 270 min, and 1.2 (0.9‐1.5) for 271‐360 min in favor of the rt‐PA group z Data from the ECASS 3 trial showed benefit between 180‐270 minutes z Number Needed to Treat to Benefit from IV TPA Across Full Range of Functional Outcomes Outcome Normal/Near Normal *Improved NNT 8.3 3.1 For every 100 patients treated with tPA, 32 benefit, 3 harmed Saver JL et al Stroke 2007; 38:2279‐2283 *Better outcome by 1 or more grades on the mRS Traditional tPA exclusions Head trauma or prior stroke in previous 3 months z Symptoms suggestive of SAH z Arterial puncture at non compressible site in previous 7 days z History of previous intracranial hemorrhage z Intracranial neoplasm, AVM, aneurysm z Recent intracranial or intraspinal surgery z BP >185/110 after 2 doses of labetolol z Active internal bleeding z ECASS‐3 (The 2008 European Cooperative Acute Stroke Study III) •Acute stroke patients treated up to 4.5 hours after onset •The odds ratio for a favorable outcome on the Rankin scale was 1.34, p=0.04 •Occurrence of symptomatic ICH was 2.4% vs 0.2% in placebo group •Mortality was 7.7% vs 8.4% in placebo group •There were additional exclusions of patients with: • Age older than 80 years • Use of oral anticoagulants regardless of INR • Baseline NIHSS>25 • History of both stroke and diabetes Summary of the AAN‐ACEP Joint Evidence‐Based Guideline z z z z tPA should be offered to patients who meet guidelines and can be treated within 3 hours (Level A) tPA should be considered for patients who meet ECASS III criteria and can be treated between 3‐4.5 hours (Level B) Systems should be in place at institutions that have the ability to do so to administer tPA safely Within ANY time window, the patient should be treated as rapidly as possible Expansion of the time window for tPA tPA may be administered 3-4.5 hours (Class IB) after stroke unless other criteria exist z Age >80 z Oral anticoagulant regardless of INR z Baseline NIHSS ≥25 z History of both stroke and diabetes z These were not addressed in the ECASS 3 study and are in need of further study and consent is recommended z tPA treatment recommendations for patients beyond 3 hours z Primary goal is treatment within 60 minutes of arrival to the facility − 3 to 4.5 hours without ECASS II exclusions — >Treat − 3 to 4.5 hours with one ECASS III exclusions— >Obtain consent prior to treatment − Neurologist consultation by phone or telemedicine for telemedicine sites recommended and call as soon as pt determined to be a potential tPA candidate Can we treat patients who do not meet the strict criteria developed 17 yr ago? z z z Age is a caution, not an exclusion Off label thrombolysis is not associated with a poorer prognosis IST-3 trial treated patients up to 6 hours and those treated within 3 hours benefitted although 95% did not meet current criteria for tPA − Most of those patients were >80 − Other exclusions were present as well Warlaw JM Lancet 2012:379:2364-72 Original NINDS Trials: Older patients with severe strokes Overall benefit lower for these patients but still a net benefit of treatment − Less death or severe disability (67% vs 86%) − Few cures but more independent patients (11% vs 5%) Is Aggressive BP control before tPA for acute ischemic stroke safe and effective? Variable No BP treatment before tPA Any BP treatment before tPA Aggressive treatment before tPA SICH % 1.6 4.0 4.2 Poor outcome (mRS 4-6) % 27 26 21 Blood pressure management in acute stroke patients z z For tPA candidates, after trying labetolol IV, may consider starting IV Nicardipine or clevidipine if SBP ≥200 before tPA For patients who are not candidates, there is no data to support lowering BP below 220/120 unless other criteria exist (e.g. hypertensive encephalopathy) tPA Exclusions Bleeding risk z Oral anticoagulant AND INR >1.7 z Heparin and elevated PTT z Platelet count <100K z Direct thrombin inhibitor and elevated sensitive lab tests (PTT, TT-thrombin time, ECT-ecarin clotting time) z Multilobar cerebral infarction on CT z tPA cautions (not absolute contraindications) z Minor or rapidly improving symptoms. z What is minor? How much improvement? z Pregnancy z Seizure at onset z Major surgery or trauma within 14 days z GI or GU hemorrhage within 21 days z MI within 3 months z No longer mentioned: major stroke deficit z Consultation is recommended when there are any contraindication/cautions Medical Legal Perils in Stroke Care z z z z z Failure to consider stroke in differential dx in young patients Failure to recognize presentations of posterior circulation strokes (case study) Failure to recognize pitfalls associated with cerebellar strokes Failure to thoroughly document the neurological exam Failure to treat with tPA—or document WHY you didn't Posterior circulation and cerebellar strokes z “Dizziness plus” − Headache − Double vision, speech articulation, swallowing, crossed symptoms z Visual fields z If you can't explain it... z Cerebellar strokes can cause death and surgery can be life saving Case study 2 z 80 year old right handed woman z PMH: HTN, CAD, hyperlipidemia, no DM z Meds: statin, losartan 100 mg/d, no ASA z z Uses a scooter, no longer walking, has 24 hour home supervision but indep in ADLS, not demented Presents with NIHSS 15 for left hemiplegia, sens loss, dysarthria, BP 182/106, gluc 103, normal CBC and plat count Case study 2 z z 90 min after symptom onset, CT showed old small right occipital infarct, 2 cm left parietal meningioma z z PMH: HTN, CAD, hyperlipidemia, no DM z z What would you do? Case study 2 z After discussing risks and benefits with her son, she was treated with tPA at 1 hour 45 minutes from last neurologically normal. 3 hours later she started moving her left side and 24 hours later NIHSS=0. Case study 3 z z z 78 year old female PMH hypertension, osteoarthritis, A fib, mild dementia, prior stroke in 2004 with excellent response, no DM Recent history: frequent falls and 4 months ago sustained pelvic fracture. Stopped warfarin at that time. She is in ECF for convalescence Case study 3 z z z Sudden L HP observed by therapist, 911 call delayed until daughter arrived. At arrival to ED, had left HP with no movement of left arm or leg and marked pain with effort. NIHSS‐10. Glucose 90, BP 168/92, normal CBC and platelet count. CT remarkable except for old right MCA infarct, results obtained 3 hours 45 min since symptom onset What would you do? Telestroke benefits for rural stroke care • • • Increasing use of teleradiology and telestroke consultation are allowing more patient to be treated at rural facilities Local “stroke champions” and education are critical to success The state department of public health has started a recognition program for hospitals who demonstrate participation in stroke care and tracking their results Documentation of LKW, ED, & CT imaging dates/times and NIHSS among stroke patients at CAH receiving stroke recognition, Montana, Jan 2012‐Jun 2013 2012 2013 Jan‐Jun (N = 46) Jul‐Dec (N = 60) Jan‐Jun (N = 38) % (n) % (n) % (n) Date and time of last known well (LKW) and ED arrival documented* 59 (27) 47 (28) 58 (22) Date and time of ED arrival and CT image completed documented** 96 (44) 92 (55) 76 (29) NIH stroke scale score documented 37 (17) 38 (23) 32 (12) *Excludes 31 patients with times < -30.0 minutes **Excludes 4 patients with times <-30.0 minutes ED arrival to CT image complete among ischemic stroke patients arriving within 4.5 hours at a CAH receiving stroke recognition, Montana, Jan 2012‐Jun 2013 N=8 N = 10 N=9 *Excludes 4 stroke patients with times < -30.0 minutes Neurologist consultation, tPA contraindication and tPA use among ischemic stroke patients at CAH receiving stroke recognition, Montana, Jan 2012‐Jun 2013 2012 2013 Jan‐Jun (N = 8) Jul‐Dec (N = 11) Jan‐Jun (N = 12) % (n) % (n) % (n) Neurologist consulted 25 (2) 91 (10) 42 (5) tPA contraindication documented (50% consulted) 63 (5) 55 (6) 33 (4) 33 (1/3) 60 (3/5) 38 (3/8) 4.1 (1/24) 7.5 (3/40) 15.0 (3/20) tPA given among patients without tPA contraindication documented (71 % consulted) tPA given among all ischemic stroke patients Telestroke demonstration My contact information: Office: 406‐455‐2570 Cell: 406‐788‐9770 Email: [email protected] Benefis One Call 800‐972‐4000