1. Stroke Acute Care Case Review Chris Whelley, MSN, RN, CNRN, SCRN Stroke Program Coordinator

2. Acute stroke clarification Evolution of acute treatment Case EMS best practice What’s to expect in the next two years Outline

3. What is included? TIA? Wake up stroke? Stroke from last week? Acute Stroke

4. 1995 NINDS tPA study published 1996 FDA approval of Alteplase for stroke up to 3 ½ hrs from stroke symptom onset 2008 European Cooperative Acute Stroke Study (ECASS)-3 2008 Safe Implementation of Thrombolysis in Stroke- Monitoring Study (SITS MOST) provided data 2009 AHA Guideline for treatment with IV tPA up to 4 ½ hrs from onset IV Thrombolysis History

5. LKN 6 am, OSH 7:11 Aphasic Right facial droop, Right arm/leg weakness 15 weeks pregnant 104/58, Plt 279, K 2.7 CT shows ischemic stroke tPA candidate but no data on safety to fetus. Family aware and very concerned about patient tPA to be administered with immediate transfer via ground Access Center Note Time: 1/1/13 0836

6. LKW at 0600 by husband, speech slurred @ 0615, HA x 3 wks 0835--GCS--15, no able to hold up neck, can't stick out tongue Able to obey commands on left---no movement on right, not able to speak, stick out tongue Able to shake yes/no 110/57, 85, 16, 98%, 97.3 A; K+--2.7, KCl started Husband coming in ambulance TPA infusing per right IV--4.491 @ 0847 09:13 report to ED

7. 15 weeks pregnant and per report has been having new headaches for several weeks otherwise healthy with no prior history of neurological disease NKDA Pre-Stroke Rankin Score: 0 - No symptoms at all Lives with husband Family History: Patient cannot provide Review of Systems: Patient cannot participate On arrival to UW

8. BP 116/65 | Resp 16 | Wt 49.89 kg (110 lb) | SpO2 100% General Appearance: Glassy stare Neurological Examination: Total NIHSS Score: 24 Mental Status: Awake, eyes open, can look toward voices but appears altered, can follow commands with eyes but otherwise does not follow commands. No speech. No obvious neglect or gaze deviation. Physical Exam 09:55

9. Cranial Nerves: PERRL, vertical eye movements intact, does not blink to threat from either side, no facial asymmetry but appears bilaterally weak. Motor: Low tone in right arm. Allows right arm and leg to fall to bed with no antigravity strength, left arm and leg fall to bed more slowly. No spontaneous movements. Reflexes: Extensor plantar response on left, flexor on right Sensory: Triple flexion bilaterally to noxious stimuli, less brisk on right PE continued

10. Imaging: CT from OSH no hemorrhage or early signs of ischemia CTA with occlusive basilar thrombosis, areas of hypodensity in left cerebellum ECG: Sinus Laboratory Results: K from OSH 2.7 CBC with WBC 10.9, Hgb 13.6, Plt 279, INR 0.9 Diagnostic Testing

11. Ms. Smith is a young woman presenting with acute onset slurred speech and right-sided weakness progressing to muteness and quadriparesis. Her neurological exam at present is remarkable for deficits referable to the bilateral corticospinal and corticobulbar tracts. Her ability to follow commands with her eyes is concerning for progression to locked-in syndrome. STAT CTA revealed a basilar occlusion. Given her severe deficits and failure to improve with tPA she was taken immediately to the endovascular suite. This was discussed with her husband, who was present and consented to the procedure. Given the severity of her symptoms it is appropriate to proceed with care despite potential harm to the fetus. We appreciate rapid response and management of our neurosurgical colleagues. The etiology of this stroke may be dissection, possibly related to hyperemesis, vs embolic from pregnancy hypercoagulability. We will of course continue to follow her during her hospital stay. Assessment

12. Was tPA Administered?: Yes - at the referring hospital IV tPA bolus date: IV tPA bolus time: 0847 - Endovascular intervention for basilar thrombosis. - Post-intervention management per Neurosurgery. - Intermittent telemetry, lipid panel, Hgb A1c for stroke evaluation Consult OB when she is stabilized to discuss pregnancy. Stroke will continue to follow, please call with any questions or concerns. Patient examined with and plan per attending Dr. Bradbury. Plan

15. Diagnosis: Basilar artery thrombosis Procedure: Vertebrobasilar angiogram with mechanical thrombectomy of basilar artery thrombosis and eventual recanalization with stent placement Findings: 1. Basilar artery thrombosis. 2. TICI III recanalization using Solitaire device with immediate rethrombosis with two attempts. 3. Enterprise stent placement within the basilar artery with eventual TICI III recanalization. Brief Operative Note

17. “…is doing extremely well this morning. She was extubated yesterday evening. She has no problems with speaking, moving her extremities or vision. She is feeling generally well overall and ‘much better’ than yesterday” Neuro exam: no singificant focal deficits MRI confirms only small areas of diffussion restriction in the right cerebellum. Next morning

18. Clinical Impression: female admitted for basilar thrombosis s/p tPA, endovascular thrombectomy, and stent placement. Patient currently presents with grossly functional cognitive-linguistic skills. Patient's speech and language were intact. No further services indicated at this time. Expected Disposition: Home with no ongoing Speech Language services Speech Language Pathology day #2

19. Assessment: Patient doing very well with gait and balance today. She appears more confident today and does not demonstrate any gait deviations. Balance appears normal as well. Pt. Is safe for d/c home when medically ready and has no ongoing PT needs at this time. Recommended Disposition: Home with no further Physical Therapy recommended at this time Plan: Discharge from Acute Physical Therapy Physical Therapy day #2

20. Clinical Impression: female admitted for new onset stroke. Patient currently presents with some generalized weakness- likely secondary deconditioning/pregnancy fatigue- which is symmetrical. Also with some mild decreased hand coordination bilaterally which may have an effect on handling dental tools. She is presently doing well with basic self cares and will have good support at home. She was educated in Home Exercise Program and appears to understand well. MVPT was also 1 point below norms, but this appears to be secondary her rushing with her answers. Encouraged her to slow down for improved success. No further OT needs identified at this time, but will continue to monitor he status until discharge for any status changes. Occupational Therapy day # 2

21. Fetal heart rate normal Ultrasound indicates normal movement of fetus OB

22. Questions?

23. Rapid access to EMS, 911 universal EMS (responders, dispatchers) trained to recognize and respond Collaboration of EMS, ED, Stroke Team Track data, improve feedback to EMS Advocate for state wide plan for EMS protocols 2007 AHA Guidelines Strategies for EMS in stroke systems

24. 100% of dispatch use high-priority EMS response at highest level available Receipt of call and dispatch less than 90 seconds for 90% of calls EMS communicators correctly ID a maximum percentage of callers experiencing stroke and dispatch EMS responders at the highest priority Recommended parameters

25. 100% of EMSs use validated prehospital stroke scale Ensure screeners over-identify stroke To provide continuous quality improvement stroke screening assessments should be compared against final diagnosis Recommendations p.2

26. EMSS less than 9 minutes 90% of time Dispatch < 1 minute Turnout < 1 minute Travel time equivalent to trauma and AMI On scene time < 15 minutes Goals for response time

27. Measured for EMS Measured for Primary Stroke Centers Measured for Comprehensive Stroke Center Ensure pre-arrival notification

28. Paul Coverdell Federal Grant Recipient State Wide Map Develop Stroke System Transport Protocols

30. State wide regional meetings Milwaukee and others October 29 th 3-hospital event in Madison

31. Public stroke education Chain of survival (again ) Lot’s of repetition of previous Intra arterial fibrinolysis can be considered in post op stroke patients Combination IV, IA may be considered Mechanical clot disruption (Merci, Penumbra, Solitaire, Trevo) 2013 AHA Guidelines

32. New designation coming Small hospitals with 24/7 CT capability Able to administer tPA quickly with access to stroke experts likely via Telestroke Acute Stroke Ready Hospital

35. EMS stroke team Portable CT scanner Doc on rig with EMS tPA in hand Cincinnati and other communities

36. Questions?