4Question Hemorrhagic stroke accounts for what percent of all strokes? A. Less than 5%B. 15% - 20%C. 50%D. 80%
5QuestionWhich one of the following events causes the majority of ischemic strokes?A. Ventricular fibrillationB. ThromboembolismC. Atrial fibrillationD. Intracerebral hemorrhage
6QuestionIn a patient suspected of having an acute brain attack, which one of the following is the best way to differentiate between an ischemic or hemorrhagic cause?A. The historyB. The physical examinationC. A CT scan of the brainD. An MRI scan of the brain
7QuestionA patient has sudden weakness of the left arm and leg. EMS is called and the patient’s blood pressure is found to be 250/150mmHg. The most appropriate action to be taken by EMS is to monitor and record the blood pressure and:A. Administer labetalol 15mg IVB. Administer nifedipine 10mg SLC. Administer NTG SLD. Do not administer any antihypertensive agent
8Question Which one of the following pairings is incorrect? A. Left brain dysfunction – right sided weaknessB. Brainstem dysfunction – slurred speechC. Cerebellum dysfunction – dyscoordinationD. Subarachnoid hemorrhage – inappropriate speech
9QuestionWhich one of the following is true regarding the “ischemic penumbra”?A. It is brain tissue with irreversible ischemiaB. It is unaffected by the use of TPAC. It is worsened by hypotensionD. Can be seen on a CT scan of the brain
10QuestionAll of the following are true statements regarding stroke, except:A. It is the leading cause of disability in the USB. It is a preventable conditionC. Death from stroke may be reduced by the treatment with TPAD. Its incidence increases with age
11Question All of the following are signs of a brainstem stroke, except: A. AphasiaB. Hemisensory lossC. Nausea and vomitingD. Vertigo
12QuestionAll of the following assessments are components of the initial on-site prehospital stroke examination, except:A. ReflexesB. SpeechC. Facial symmetryD. Arm strength
13Background (USA) #1 Disability #3 Killer 50 million dollars per year 20% mortality50 million dollars per yearOld therapyrehabilitationreduce risk of future strokesCurrent therapyacute interventionsreduce brain area of ischemiaBlood sugarBlood pressure
14Background Median Hours to ED Arrival (EMS vs Car) 2nd Goal Goal Kothari.(Cincinnati) Ann Emerg Med 1999; 33: 1.
15Background Median Time (Hours) Spent Evaluating Stroke Patients (Prehospital = time at home + EMS [small part])Kothari (Cincinnati). Ann Emerg Med 1999; 33: 1.
16Background - Who is Eligible O’Connor RE. Ann Emerg Med 1999; 33: 9-14
22Ischemic Stroke: Nonmodifiable Risk Factors Advanced ageMale genderAfrican-American heritageFamily history of early stroke or MI
23Intracerebral Hemorrhage Most common cause:chronic hypertensionOther causes:Vessel malformationTumor, bleeding abnormalitiesBleeding into brain
24Subarachnoid Hemorrhage Most common cause:aneurysm ruptureOther causes:Vessel malformationTumor, bleeding abnormalitiesBleeding around brain
25Transient Ischemic Attack (TIA) Reversible focal dysfunction, usually lasts minsAmong TIA pts who go to ED:5% have stroke in next 2 days25% have recurrent event in next 3 monthsDecrease stroke risk with proper therapy:artery source—antiplatelet (ASA), surgeryheart source—anticoagulation (warfarin)
26BackgroundRisk of Stroke Following ATransient Ischemic Attack
27Time Is Brain: Save The Penumbra CoreClot in Artery
28Time is Brain: Save the Penumbra In first few hours of ischemic stroke, brain tissue can still be savedZone of reversible ischemia (“penumbra”) surrounds core of irreversible infarctionPatient symptoms due to both infarcted core and ischemic penumbraOne cannot determine by exam how much brain can still be saved
29Time is Brain: Save the Penumbra Thrombolytic (fibrinolytic) agent t-PA can limit brain damage safely if given w/in 3 h—it reduces risk of disability due to ischemic stroke by 30%Administer t-PA only if:clinical diagnosis confirmed by CT scanwithin 3 hours of onsetage 18 or olderno other contraindications
30Major Stroke Syndromes LEFT HEMISPHERERIGHT HEMISPHEREBRAINSTEMCEREBELLUMHEMORRHAGE1122534453
31Left (Dominant) Hemisphere: Typical Signs (Right Side and Aphasia) Right Visual Field DeficitAphasiaLeft Gaze PreferenceRight HemiparesisRight Hemisensory Loss
32Right (Nondominant) Hemisphere: Typical Signs (Left Side) Left Hemi-inattentionLeft Visual Field DeficitRight Gaze PreferenceLeft HemiparesisLeft Hemisensory Loss
33Brainstem: Typical Signs (Both Sides) Crossed Signs (1 side of face and contralateral bodyQuadriparesisSensory Loss in All 4 LimbsHemiparesis Hemisensory Loss
36Symptoms Suggestive of Hemorrhage Both Subarachnoid and Intracerebral Hemorrhage:HeadacheNausea, VomitingDecreased LOCSubarachnoid Hemorrhage:Intolerance to LightNeck Stiffness / PainIntracerebral Hemorrhage:Focal Signs Such as Hemiparesis
37The Focused Neurologic Assessment and Evaluation
38Cincinnati and LA Prehospital Stroke Scales Perform on scene during Primary Surveyunder “D” – Disability:SpeechFacial DroopArm DriftGrip“Speech, Droop, Drift, Grip!”
39(Aphasia = left hemisphere Dysarthria = cranial nerves) Speech: Repeat Phrase“You can’t teach an old dog new tricks.”Abnormal:Wrong or inappropriate words (aphasia)Slurred words (dysarthria) or unable to speak(Aphasia = left hemisphereDysarthria = cranial nerves)
42Prehospital Stroke Scale GripNormal right and leftAbnormal right or absent rightAbnormal left or absent leftComparison of sides
43Prehospital Stroke Identification Smith. Prehospital Emerg Care 1998; 2: 170.Kidwell (Los Angelos) Stroke 2000; 31: 71.Kothari (Cincinnati). Ann Emerg Med 1999; 33: 373.
44Cincinnati Prehospital Stroke Scale Normal Patient Click picture to play video
45Miami Emergency Neurologic Deficit Exam Expanded Prehospital Stroke Exam MENTAL STATUSCHECK IF ABNORMALLevel of Consciousness (AVPU)Speech “You can’t teach an old dog new tricks.” (repeat)Abnormal = wrong words, slurred speech, no speechQuestions (age, month)Commands (close, open eyes)CRANIAL NERVESFacial Droop (show teeth or smile) RT LTAbnormal - one side does not move as well as otherVisual Fields (four quadrants)Horizontal Gaze (side to side)LIMBSMotor–Arm Drift (close eyes and hold out both arms) RT LTAbnormal–arm can’t move or drifts downLeg Drift (open eyes and lift each leg separately)Sensory–Arm and Leg (close eyes and touch, pinch)Coordination–Arm and Leg (finger to nose, heel to shin)
46Miami Emergency Neurologic Deficit Exam Normal Patient Click picture to play video
47Cincinnati Prehospital Stroke Scale Left Hemispheric Stroke Click picture to play video
48Miami Emergency Neurologic Deficit Exam Left Hemispheric Stroke Click picture to play video
49Diagnosis and Management PrehospitalExclude masqueradershypoglycemia/hyperglycemiadrugs/toxinstraumahypoxiaNeurologic screenCincinnati/LA prehospital stroke scalenot meant to be 100% accurate
50Management - GlucoseNeurologic Effects of Lo glucose vs. Very Hi glucoseon Infarcted Brain (Rabbit Model)Thoralf. Stroke 1999; 30:
51Management - GlucosePulsinelli. Am J Med 1983; 74: 540.
52Management - Blood Pressure Relationship of CNS tissue perfusion (SPECT scan)to drop in BP after treatmentLisk. Arch Neurol 1993; 50: 855.
53Acute Stroke Patients: Indications for Antihypertensive Therapy In general:Consider: absolute level of BP?If BP: >185/>110 mm Hg = fibrinolytic therapy contraindicatedConsider: other than BP, is patient candidate for fibrinolytics?If patient is candidate for fibrinolytics: treat initial BP >185/>110 mm HgConsider: response to initial efforts to lower BP in ED?If treatment brings BP down to <185/110 mm Hg: give fibrinolyticsConsider: ischemic vs hemorrhagic stroke?Treat BP in the / mm Hg range the sameThe obvious: no fibrinolytics for hemorrhagic stroke
54Treatment of High BP in Acute Stroke Patients BP Level>185/>110 mm HgDuring/after fibrinolytic treatment BP may rise:DBP >140 mm Hg>230/ mm Hg/ mm HgFibrinolytic CandidateNitropaste or labetalol IVif BP remains elevated:no fibrinolyticsNitroprussideinfusionLabetalol, then prnnitroprussideLabetalolNot a Fibrinolytic CandidateNo acute therapy indicatedNitroprussideinfusionLabetalolAcute therapy only if hypertensive urgency also presentReview suggested antihypertensive therapy for patients with suspected ischemic stroke.Note: Course participants with a first printing of the 1997 ACLS Textbook should correct it to reflect the most recent versions of Tables 7 and 8 as published in the 1997 ECC Handbook.MAP is estimated by one third the sum of systolic and double diastolic pressure.Labetalol should be avoided in patients with asthma, cardiac failure, or severe abnormalities in cardiac conduction. For refractory hypertension, alternative therapy may be considered with sodium nitroprusside, enalapril, or nicardipine.
55Diagnosis and Management ED DiagnosisHistory and Physical in EDSupplemented with CTnormal in 1st hoursThrombolytic Therapy
56Emergent CT Scan Is necessary to rule out nonstroke cause of symptoms Is necessary to differentiate ischemic vs. hemorrhagic strokeExam alone cannot distinguish stroke vs. nonstroke or ischemia vs. hemorrhage
57Noncontrast CT Scan: Ischemic Stroke (Left Hemisphere) R Hours LR Days LSubtle blurring and compression of sulciObvious dark changes of infarction
58Noncontrast CT Scan: Hemorrhagic Strokes Intracerebral HemorrhageSubarachnoid HemorrhageR LR L“Ball” of whiteblood in thalamusWhite blood incisterns & 4th ventricle
59What Pathology Does This Scan Show? Scan AScan A has a well-defined hypodensity in the left hemisphere consistent with a significant acute ischemic event (3 hours in duration). As a result, this patient would not be a candidate for fibrinolytics. Note that if the hypodensity is thought to be 3 months old, it does not constitute a contraindication to fibrinolytics.There are hyperdense (white) areas that represent calcification in the choroid plexus rather than bleeding.
60What Pathology Does This Scan Show? Scan AHypodense area:Ischemic area with edema, swellingIndicates >3 hours oldNo fibrinolytics!Scan A has a well-defined hypodensity in the left hemisphere consistent with a significant acute ischemic event (3 hours in duration). As a result, this patient would not be a candidate for fibrinolytics. Note that if the hypodensity is thought to be 3 months old, it does not constitute a contraindication to fibrinolytics.There are hyperdense (white) areas that represent calcification in the choroid plexus rather than bleeding.RightLeft
61What Pathology Does This Scan Show? Scan BScan B shows a large left frontal intracerebral hemorrhage. Intraventricular hemorrhage is present. This patient is not a candidate for fibrinolytics.
62What Pathology Does This Scan Show? Scan B(White areas indicatehyperdensity = blood)Large left frontalintracerebral hemorrhage.Intraventricular bleedingis also presentNo fibrinolytics!Scan B shows a large left frontal intracerebral hemorrhage. Intrav- entricular hemorrhage is present. This patient is not a candidate for fibrinolytics.RightLeft
63What Pathology Does This Scan Show? Scan CScan C shows diffuse areas of white (hyperdense) images consistent with an acute subarachnoid hemorrhage. The hemorrhage is visible in several areas on the surface of the brain.A patient like this is not a candidate for fibrinolytic therapy. CT findings may be more subtle than these.
64What Pathology Does This Scan Show? Scan CAcute subarachnoid hemorrhageDiffuse areas of white (hyperdense) imagesBlood visible in ventriclesand multiple areas on surface of brainScan C shows diffuse areas of white (hyperdense) images consistent with an acute subarachnoid hemorrhage. The hemorrhage is visible in several areas on the surface of the brain.A patient such as this is not a candidate for fibrinolytic therapy. CT findings may be more subtle than these.
65Management - Thrombolytics Percent of Patients with Minimal/No deficit at 3 monthsNINDS. New Engl J Med 1995; 333: 1581.
66Fibrinolytic Therapy: Yes/No Checklist Inclusion Criteria(all “Yes” boxes must be checked beforefibrinolytics are given)Yes Age 18 years or older Clinical diagnosis of ischemic stroke causing a measurable neurologic deficit Time of symptom onset well established to be <180 minutes before treatment would beginReview inclusion criteria: all must be present for fibrinolytic therapy to be initiated.
67Fibrinolytic Therapy: Yes/No Checklist Exclusion Criteria(all “No” boxes must be checked before fibrinolytics are given):No Evidence of intracranial hemorrhage on noncontrast head CT Only minor or rapidly improving stroke symptoms High suspicion of subarachnoid hemorrhage even if CT is normal Active internal bleeding (eg, gastrointestinal bleeding or urinary bleeding within last 21 days) Known bleeding diathesis, including but not limited to— Platelet count < mm3— Patients who received heparin in last 48 hours; have elevated PTT— Recent anticoagulant use (eg, coumadin); have elevated PTReview exclusion criteria: all must be absent for fibrinolytic therapy to be initiated.Note: The instructor has the option of indicating the presence of one exclusion criterion to determine if participants will later correctly exclude the patient from fibrinolytic therapy if the ischemic stroke branch is used.
68Fibrinolytic Therapy: Yes/No Checklist Exclusion Criteria (cont’d)(all “No” boxes must be checked before fibrinolytics are given):No <3 mo ago: intracranial surgery, head trauma, previous stroke <14 days ago: major surgery or serious trauma <7 days ago: lumbar puncture Recent arterial puncture at noncompressible site History of intracranial hemorrhage, AV malformation, or aneurysm Witnessed seizure at start of stroke Recent acute myocardial infarction SBP >185 mm Hg/DBP >110 mm Hg; confirmed several times BP must be treated aggressively to bring within these limitsReview exclusion criteria: all must be absent for fibrinolytic therapy to be initiated.
69Management - thrombolytics Requirements - all within 3 hoursRecognition/identificationpotentially eligible patientsHistoryAwaken with weakness does NOT count)Exclusion criteriaExamdetailedNIH stroke scaleCT scanmust be read by neuro-radiologist (subtle exclusions)Consent
70Management - other options New neuroprotective agentsSelective intra-arterialthrombolyticsangioplasty?Stents/coils?EXTENDS window to 4-6 hours
71Acute Stroke Algorithm Suspected StrokeEMS assessments and actionsImmediate assessments performed by EMSpersonnel includeCincinnati Prehospital Stroke Scale (includes difficulty speaking, arm weakness, facial droop)Los Angeles Prehospital Stroke ScreenAlert hospital to possible stroke patientRapid transport to hospitalDetectionDispatchDeliveryDoorImmediate assessment:<10 minutes from arrivalAssess ABCs, vital signsProvide oxygen by nasal cannulaObtain IV access; obtain blood samples (CBC, electolytes, coagulation studies)Check blood sugar; treat if indicatedObtain 12-lead ECG, check for arrhythmiasPerform general neurological screening assessmentAlert Stroke Team: neurologist, radiologist, CT technicianImmediate neurological assessment:<25 minutes from arrivalReview patient historyEstablish onset (<3 hours required for fibrinolytics)Perform physical examinationPerform neurological examination:Determine level of consciousness (Glasgow Coma Scale)Determine level of stroke severity (NIH Stroke Scale or Hunt and Hess Scale)Order urgent noncontrast CT scan (door-to–CT scan performed: goal <25 minutes from arrival)Read CT scan (door-to–CT read: goal <45 minutes from arrival)Perform lateral cervical spine x-ray (if patient comatose/history of trauma)Have students follow the algorithm in their textbook or in the 2000 ECC Handbook.
73Click picture to play video Case 1: On sceneClick picture to play video
74Case 1:Transport (patient is 60 / month is December) Click picture to play video
75Case 1: Discussion 1. Is this more likely a stroke or stroke mimic? 2. What are the physical findings?3. Where in the brain is the abnormality?4. Is the radio report complete?5. Is this patient a candidate for t-PA?1. What stroke syndrome do you suspect?- Left hemisphere2. What are the physical findings?- Expressive aphasia- Right facial droop- Right visual field cut- Left gaze preference. Right gaze deficit.- Right arm drift- Right leg drift- Right hemi-sensory loss- Normal coordination, but limited on right by weakness3. Is the radio report complete?-4. Is this patient a candidate for thrombolytics?- Yes
76Click picture to play video Case 2: On SceneClick picture to play video
77Case 2:Transport (patient is 45 / month is December) Click picture to play video
78Click picture to play video Case 2: Radio ReportClick picture to play video
79Case 2: Discussion 1. Is this more likely a stroke or stroke mimic? 2. What are the physical findings?3. Where in the brain is the abnormality?4. Is the radio report complete?5. Is this patient a candidate for t-PA?
80Click picture to play video Case 3: On SceneClick picture to play video
81Case 3:Transport (patient is 48 / month is October) Click picture to play video
82Click picture to play video Case 3: Radio ReportClick picture to play video
83Case 3: Discussion 1. Is this more likely a stroke or stroke mimic? 2. What are the physical findings?3. Where in the brain is the abnormality?4. Is the radio report complete?5. Is this patient a candidate for t-PA?
84Click picture to play video Case 4: On SceneClick picture to play video
85Case 4:Transport (patient is 69 / month is December) Click picture to play video
86Click picture to play video Case 4: Radio ReportClick picture to play video
87Case 4: Discussion 1. Is this more likely a stroke or stroke mimic? 2. What are the physical findings?3. Where in the brain is the abnormality?4. Is the radio report complete?5. Is this patient a candidate for t-PA?
88Maximum Intervals Recommended by NINDS Summary Key Evaluation Targets for Stroke Patient: Potential Fibrinolytic Candidate?Maximum Intervals Recommended by NINDSDoor-to–doctor first sees patient …….………… 10 minDoor-to–CT completed …….………………….. 25 minDoor-to–CT read ...…………..………………… 45 minDoor-to–fibrinolytic therapy starts …………… minNeurologic expertise available* …..…………… 15 minNeurosurgical expertise available* …………… 2 hoursAdmitted to monitored bed ..……...…………… 3 hoursReview times.Answer 1: Review the patient’s history, verify time of symptom onset, and perform brief physical and neurologic examinations.Answer 2: The NIHSS measures neurologic function, which correlates with ischemic stroke severity and long-term outcome. It can be performed in 7 minutes and can be performed simultaneously with initial admission procedures, so it should not delay other assessment or therapy. It enables performance of serial standardized neurologic evaluation over time by a nurse or physician. This stroke scale is shown in the ACLS Textbook and the 2000 ECC Handbook.The NIHSS is not a comprehensive neurologic exam, and further studies may be required. The NIHSS evaluates the following 5 areas, and the resulting score (0-42) will guide decisions about therapy:Level of consciousnessVisual assessmentMotor functionSensation and neglectCerebellar functionTraining in the NIHSS is beyond the scope of this course but will be included in the advanced ACLS course. Videotapes are available to teach the use of this scale.Additional scales: Hunt and Hess Scale for subarachnoid hemorrhage and Glasgow Coma Scale. See the ACLS Textbook.