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BRAIN ATTACK UNDERSTANDING AND MANAGING ACUTE STROKE Carolyn Walker RN, BN. January 2011.

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Presentation on theme: "BRAIN ATTACK UNDERSTANDING AND MANAGING ACUTE STROKE Carolyn Walker RN, BN. January 2011."— Presentation transcript:

1 BRAIN ATTACK UNDERSTANDING AND MANAGING ACUTE STROKE Carolyn Walker RN, BN. January 2011

2 Brain Attack: Understanding and Managing Acute Stroke Learning Objectives: Upon completion of this session, participants will be able to: Describe the 2 major types of stroke Describe the 2 major types of stroke Identify the location of stroke given stroke symptoms Identify the location of stroke given stroke symptoms Describe the management of hypertension in acute stroke Describe the management of hypertension in acute stroke Explain the appropriate management of acute ischemic stroke Explain the appropriate management of acute ischemic stroke

3 Epidemiology of Stroke: The Canadian Perspective  50,000 new stroke patients/year in Canada †  5,500 Albertans suffer a stroke each year  Every 10 minutes someone in Canada suffers a “brain attack”  3 rd leading cause of death in Canada  The leading cause of adult disability  200,000–300,000 stroke survivors †  Cost to society: $ million/yr Alberta  28% of stroke patients are under age 65* † Statistics Canada

4 What is a stroke? BLOCKAGEBREAKAGE blood vessel occlusion or blood vessel rupture (clot / atherosclerosis) (clot / atherosclerosis) sudden interruption in cerebral blood flow brain injury to affected area brain death of affected area

5 Stroke: Brain Attack Stroke is a “brain attack” Stroke is an EMERGENCY!

6 Frequency of Stroke by Type Ischemic (85%) Thrombotic (54%), Embolic (31%) Ischemic (85%) Thrombotic (54%), Embolic (31%) Ischemic Stroke – 65% Ischemic Stroke – 65% TIA – 20% TIA – 20% symptoms resolve symptoms resolve no brain cell death no brain cell death 20-40% of strokes are proceeded 20-40% of strokes are proceeded by TIA by TIA Hemorrhagic (15%) Hemorrhagic (15%) Intracerebral – 10% Intracerebral – 10% Subarachnoid – 5% Subarachnoid – 5% Blockage Breakage

7 The Brain Cerebrum Cerebrum Diencephalon Diencephalon Cerebellum Cerebellum Brainstem Brainstem

8 Cerebrum Center for highest function Center for highest function Governs thought, memory, reasoning, sensation and voluntary movement Governs thought, memory, reasoning, sensation and voluntary movement Divided into two hemispheres Divided into two hemispheres Left Hemisphere Left Hemisphere dominant in 95% of people dominant in 95% of people Right Hemisphere Right Hemisphere

9 Functions of Cerebral Hemispheres PHOTO: Courtesy of National Stroke Association

10 Cerebellum

11 Motor and Sensory Function PHOTO: Courtesy of National Stroke Association

12

13 Cerebrum Basal ganglia Basal ganglia Bands of grey matter deep within the cerebral hemispheres Bands of grey matter deep within the cerebral hemispheres Control automatic associated movements Control automatic associated movements i.e. arm swing alternating with leg movement i.e. arm swing alternating with leg movement posture posture

14 Diencephalon Includes thalamus and hypothalamus Includes thalamus and hypothalamus Extends from cerebrum to midbrain Extends from cerebrum to midbrain Surrounds 3 rd ventricle Surrounds 3 rd ventricle Thalamus Thalamus Receives sensory input Receives sensory input Relay station to cerebral cortex Relay station to cerebral cortex Hypothalamus Hypothalamus Major control centre Major control centre Regulation of temp, H 2 O balance, sleep, behavior Regulation of temp, H 2 O balance, sleep, behavior Coordinator of autonomic nervous system activity Coordinator of autonomic nervous system activity

15 Cerebellum Located under occipital lobe Located under occipital lobe Unconscious motor coordination of voluntary movement Unconscious motor coordination of voluntary movement i.e. complex coordination of different muscles needed to juggle, swim, etc. i.e. complex coordination of different muscles needed to juggle, swim, etc. Equilibrium Equilibrium Muscle tone Muscle tone

16 Brain Stem Central core of brain Central core of brain Consists mostly of nerve fibers Consists mostly of nerve fibers Midbrain Midbrain Auditory/visual systems Auditory/visual systems Pons Pons Respiratory centers Respiratory centers Medulla Medulla Respiratory and vasomotor control Respiratory and vasomotor control

17 Blood Supply to the Brain PHOTO: Courtesy of National Stroke Association

18 Blood Supply to the Brain

19 Carotid Arteries & Branches: Carotid Arteries & Branches: anterior 2/3 cerebral of hemispheres Vertebral Arteries & Branches: Vertebral Arteries & Branches: posterior and medial regions of hemispheres brainstem diencephalon (thalamus/hypothalamus) cerebellum Courtesy Genentech Courtesy Genentech 90% of all strokes 10% of all strokes

20 Hemorrhagic Stroke Intracerebral HemorrhageSubarachnoid hemorrhage

21 Intracerebral Hemorrhage Result of ruptured Result of ruptured Blood vessel Hypertension most Hypertension most common cause Usual Presentation: Usual Presentation: Headache Headache Hemiplegia Hemiplegia Decreased level Decreased level of consciousness Nausea & Vomiting Nausea & Vomiting

22 Subarachnoid Hemorrhage Blood vessel ruptures & bleeds into subarachnoid space Blood vessel ruptures & bleeds into subarachnoid space (Aneurysms/arteriovenous malformations ) (Aneurysms/arteriovenous malformations ) “Worst headache of one’s life” “Worst headache of one’s life” Nausea & vomiting Nausea & vomiting Neck stiffness Neck stiffness Neurologic signs don’t fit Neurologic signs don’t fit pattern of a single blood vessel Varying level of consciousness Varying level of consciousness

23 Management of SAH and ICH: The First Few Hours Correct airway, breathing or circulation Correct airway, breathing or circulation Treat severe elevation of BP Treat severe elevation of BP Obtain neurosurgical consult Obtain neurosurgical consult Treat elevated intracranial pressure Treat elevated intracranial pressure Admin anticonvulsant therapy if seizures Admin anticonvulsant therapy if seizures

24 Recommendations: Maintain SBP < 180 mmHg and DBP < 100 mmHg MAP < 130 mmHg if history of hypertension MAP < 130 mmHg if history of hypertension DO NOT REDUCE BP BY MORE THAN 20% CONTACT STROKE SPECIALIST AT COMPREHENSIVE STROKE CENTER! Intracerebral Hemorrhage: Hypertension Management

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26 Ischemic Stroke - The Problem

27 Etiology of Ischemic Stroke Graphics courtesy Boehringer Ingelheim

28 Classifications of Ischemic Stroke Small vessel disease Small vessel disease Lacunar infarction Lacunar infarction Large vessel disease Large vessel disease Artery to artery emboli (large artery atherosclerosis) Artery to artery emboli (large artery atherosclerosis) Cardioembolic Cardioembolic Cryptogenic (Don’t know the Cause) Cryptogenic (Don’t know the Cause) Other (Cocaine, coagulopathies) Other (Cocaine, coagulopathies)

29 Progression of Ischemic Stroke Graphics courtesy Boehringer Ingelheim

30 TIME IS BRAIN! In a typical large vessel acute ischemic stroke… million neurons - 14 billion synapses - 12 km of myelinated fibers are destroyed each minute … (JL Saver, 2006)

31 Symptoms of “Brain Attack” Speech Strength Sight

32

33 ACUTE STROKE OUTCOMES CAN BE IMPROVED IF WE PROVIDE A RAPID COORDINATED RESPONSE!

34 Approaches to Acute Therapy Neuroprotection Neuroprotection Studies* Studies* Reperfusion Reperfusion

35 REPERFUSION - Thrombolytic Agents Intravenous rt-PA Intravenous rt-PA Strict protocols for use with ischemic stroke Strict protocols for use with ischemic stroke Improves outcomes compared to the risk of serious bleeding Improves outcomes compared to the risk of serious bleeding

36 Canadian Stroke Strategy: Best Practice Recommendations 2010 All patients with disabling acute ischemic stroke who can be treated within 4.5 hours after symptom onset should be evaluated without delay to determine their eligibility for treatment with t-PA. All patients with disabling acute ischemic stroke who can be treated within 4.5 hours after symptom onset should be evaluated without delay to determine their eligibility for treatment with t-PA.

37 Diminishing Returns over Time Favorable Outcome (mRS 0-1, BI , NIHH 0-1) at Day 90 Adjusted odds ratio with 95% confidence interval by stroke onset to treatment time (OTT) ITT population (N=2776) Pooled Analysis NINDS tPA, ATLANTIS, ECASS-I, ECASS-II Courtesy Brott T et al

38 REPERFUSION Intra-arterial lytic Intra-arterial lytic ultrasonic clot-busting ultrasonic clot-busting

39 REPERFUSION: Devices - Clot Retrieval Mechanical Thrombectomy Devices - MERCI study: MERCI device Mechanical Embolus Removal in Cerebral Ischemia Mechanical Embolus Removal in Cerebral Ischemia - Penumbra device

40 Canadian Stroke Strategy: Best Practice Recommendations 2010 There remain situations where there are sparse or little clinical trial data to support the use of thrombolytic therapy: Paediatric stroke Paediatric stroke Over 80 years with diabetes Over 80 years with diabetes Present within time window but do not meet current criteria for treatment with IV t-PA Present within time window but do not meet current criteria for treatment with IV t-PA Intra-arterial thrombolysis Intra-arterial thrombolysis Treat based on clinical decision of physician and family

41 EMS Protocol- Arrival at scene PRIORITY IS LOAD AND GO ABC’s first Determine time last known to be normal Acute Stroke Screen Perform directed neurological assessment Blockage or Breakage?

42 Onset Time Onset Time = Time when patient was last seen well Onset Time = Time when patient was last seen well Requires detective skills Requires detective skills

43 Pre-Hospital Care: Direct transport to Primary Stroke Centre (PSC) A standardized acute stroke diagnostic screening tool should be used by paramedics A standardized acute stroke diagnostic screening tool should be used by paramedics Pts with symptoms of stroke should be transported without delay to the closest institution that provides emergency stroke care Pts with symptoms of stroke should be transported without delay to the closest institution that provides emergency stroke care Direct transport protocols must be in place Direct transport protocols must be in place Paramedics must notify the receiving facility Paramedics must notify the receiving facility Transfer care to receiving facility Transfer care to receiving facility without delay (scene time < 10 min) without delay (scene time < 10 min) EMS Stroke Screening Form EMS Stroke Screening Form

44 minutes

45 8 miles 40 miles vs CT scanner Local hospital No CT scanner 70 miles Helical or multislice CT scanner 24h/365d coverage Primary Stroke Center 170 miles intraclot lysis Interventional Facilities- interventional neurorad, neurosurgery Comprehensive Stroke Center ICH evacuation vs Early ICA revascularization

46 Alberta Stroke Centre Locations Primary Stroke Centre (PSC): 14 CT scan availability Door to CT < 20 min. with a pre-alert Stroke expertise on-site or available by Telestroke link r-tPA treatment availability May not be available 24/7 Comprehensive Stroke Centre (CSC): 3 CT scan availability Door to CT < 20 minutes with a pre-alert Stroke team on-site Neurological expertise on-site Neurointerventional expertise on-site Central hub of stroke Neurologist expertise in a telestroke network

47 Initial Management of Stroke: A. Immediate General Assessment Assess A B C’s, vital signs (BP, HR, Temp***) Assess A B C’s, vital signs (BP, HR, Temp***) Provide oxygen (O2 sats >95%, if COPD >90% ) Provide oxygen (O2 sats >95%, if COPD >90% ) Start an IV Line (large bore)- no dextrose Start an IV Line (large bore)- no dextrose 12 Lead ECG / cardiac monitoring 12 Lead ECG / cardiac monitoring Obtain blood samples (CBC, lytes, Cr, gluc, PTT, INR) Obtain blood samples (CBC, lytes, Cr, gluc, PTT, INR) Check Blood Sugar Levels*** Check Blood Sugar Levels*** Perform general neurological screening Perform general neurological screening Alert Stroke Team Alert Stroke Team

48 Canadian Stroke Strategy: Best Practice Recommendations 2010 Monitoring in the acute phase should include Monitoring in the acute phase should include HR and rhythm, BP, temp, O2 sat, hydration, swallowing ability and presence of seizure activity HR and rhythm, BP, temp, O2 sat, hydration, swallowing ability and presence of seizure activity Initial blood work should include Initial blood work should include CBC, lytes, Cr, urea, glucose, INR, PTT, TSH, fasting lipids, CK and troponin CBC, lytes, Cr, urea, glucose, INR, PTT, TSH, fasting lipids, CK and troponin Neurovascular Imaging – should undergo brain imaging (MRI or CT) immediately Neurovascular Imaging – should undergo brain imaging (MRI or CT) immediately Vascular imaging of the brain and neck arteries ASAP Vascular imaging of the brain and neck arteries ASAP Cardiovascular investigations Cardiovascular investigations After initial ECG-daily ECG’s x 72 hrs After initial ECG-daily ECG’s x 72 hrs May also monitor x 72 hrs to detect afib May also monitor x 72 hrs to detect afib Echocardiography if suspect embolic stroke Echocardiography if suspect embolic stroke

49 Canadian Stroke Strategy: Best Practice Recommendations 2010 Acute Aspirin Therapy Acute Aspirin Therapy All stroke pts not on antiplatelet therapy should be given at least 160 mg of ASA immediately as a one time loading dose after brain imaging excludes hemorrhage All stroke pts not on antiplatelet therapy should be given at least 160 mg of ASA immediately as a one time loading dose after brain imaging excludes hemorrhage If treated with t_PA- delay ASA until after 24 hour CT excluding hemorrhage If treated with t_PA- delay ASA until after 24 hour CT excluding hemorrhage If taking ASA may consider plavix If taking ASA may consider plavix

50 Hypertension During Acute Stroke Systolic BP > 160mmHg is seen in over 60% stroke patients (Robinson et al, Cerebrovasc Dis., 1997) Systolic BP > 160mmHg is seen in over 60% stroke patients (Robinson et al, Cerebrovasc Dis., 1997) Often transient, lasting hours and in most patients does not require treatment. Often transient, lasting hours and in most patients does not require treatment. Little evidence and no benefit seen for rapid lowering of BP in acute stroke without rt-PA Little evidence and no benefit seen for rapid lowering of BP in acute stroke without rt-PA

51 Blood Pressure Management: Recommendations: Recommendations: Hold emergency hypertension treatment unless: Hold emergency hypertension treatment unless: SBP > 220mmHg or DBP > 120mmHg SBP > 220mmHg or DBP > 120mmHg Be aware…aggressive lowering of BP may cause neurological worsening Avoid Over Treating!

52 B. Immediate Neurological Assessment Review patient history and risk factors Review patient history and risk factors Establish onset of stroke symptoms Establish onset of stroke symptoms NPO pending swallow screen NPO pending swallow screen Perform physical exam Perform physical exam Determine LOC (GCS) Determine LOC (GCS) Determine level of severity (NIH stroke scale) Determine level of severity (NIH stroke scale) Transfer for CT exam: possible t-PA Transfer for CT exam: possible t-PA Determine if Hemorrhagic or Ischemic Determine if Hemorrhagic or Ischemic

53 C. Immediate Treatment Determine if Hemorrhagic or Ischemic? Determine if Hemorrhagic or Ischemic? Hemorrhagic Hemorrhagic Reverse anticoagulants Reverse anticoagulants Reverse bleeding disorder Reverse bleeding disorder Monitor neurological condition Monitor neurological condition Treat blood pressure as required Treat blood pressure as required Ischemic Ischemic Thrombolytics Thrombolytics Neuroprotectants? Neuroprotectants?

54 D. Continued Management Continue therapies begun in ER Continue therapies begun in ER Implement Stroke Orders Implement Stroke Orders Monitor patient status (vital signs, temp, NIHSS, glucose, fluid balance, nutrition, etc.) Monitor patient status (vital signs, temp, NIHSS, glucose, fluid balance, nutrition, etc.) Initiate interventions to prevent medical or neurologic complications Initiate interventions to prevent medical or neurologic complications Treat serious co-morbid diseases or risk factors Treat serious co-morbid diseases or risk factors Perform evaluations to determine the cause of stroke Perform evaluations to determine the cause of stroke

55 D. Continued Management Integrated Multidisciplinary Stroke Care Multidisciplinary Stroke Unit Emergency Department t-PA / ICU Direct In Hospital Rehab Institutional Care + Rehab Out patient Rehab Home

56 Emergent Stroke Care and the Chain of Survival Identify symptoms Calling 911 EMS System ED Staff / Stroke team Stroke Unit Rehab / Prevention


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