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Update on Stroke Management

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Presentation on theme: "Update on Stroke Management"— Presentation transcript:

1 Update on Stroke Management
Live from JJ Baumann MS, RN, CNS

2 Focus on providing treatment quickly!
Ischemic Stroke Focus on providing treatment quickly! Patients get treatment faster if : Stroke severity is high Arrive by ambulance Arrival during regular hours Faster treatment times were associated with: Reduced in-hospital mortality Reduced symptomatic intracranial hemorrhage Increased independent ambulation at discharge Increased discharge to home Saver et al. Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA. 2013;309(23):

3 Goal door to needle time < 60 minutes
Raising the bar… Meet goal door to needle time in 80% of cases

4 Ischemic Stroke Treatment

5 Alteplase – Extending the Window
ECASS 3 extended the time window for tPA… hour window Exclusions: > 80 years old Taking oral anticoagulants regardless of INR Baseline NIHSS > 25 > 1/3 MCA territory has injury on CT History of stroke and diabetes Not FDA approved!

6 Alteplase and the New Anticoagulants
Direct factor Xa inhibitors – do not use tPA unless not used for more than 2 days or sensitivity tests (aPTT, INR, platelet count, and ECT or TT) are normal

7 Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial Raul G Nogueira, Helmi L Lutsep, Rishi Gupta, Tudor G Jovin, Gregory W Albers, Gary A Walker, David S Liebeskind, Wade S Smith, for theTREVO 2 Trialists Lancet 2012; 380: 1231–40 Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial Jeffrey L Saver, Reza Jahan, Elad I Levy, Tudor G Jovin, Blaise Baxter, Raul G Nogueira, Wayne Clark, Ronald Budzik, Osama O Zaidat, for the SWIFT Trialists Lancet 2012; 380: 1241–49

8 Stent retrievers are preferred over
Neuro Intervention? SWIFT Primary efficacy outcome recanalisation without ICH Solitaire 61% vs. Merci 24%, p<0.0001 TREVO 2 Primary efficacy outcome TICI score 2-3 Trevo 86% vs. Merci 60%, p<0.0001 Stent retrievers are preferred over MERCI or Penumbra

9 Ischemic Stroke Blood Pressure
Hold BP medications unless SBP > 220 or DBP > 120 Lower 15% in the first 24 hours

10 Ischemic Stroke - ALIAS
ALIAS - High-Dose Albumin Therapy for Neuroprotection in Acute Ischemic Stroke (M Ginsberg, MD) Use albumin to reduce brain swelling and improve neurologic outcomes. Stopped due to frutility. No benefit.

11 Ischemic Stroke Prevention
RE-LY Trial: Dabigatran versus Warfarin in Patients with Atrial Fibrillation Connolly SJ, Ezekowitz MD, et al. NEJM. 2009;361;1-13. ROCKET AF: Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation Patel, MR, et al. N Engl J Med 2011; 365: ARISTOTLE Trial: Apixaban non-inferior to warfarin in AF patients. Granger, CB, et al. N Engl J Med 2011; 365:

12 Intracranial Hemorrhage
Phase 2 trial Promising results: ICH volume smaller 35% reduction in mortality Less disability Slightly more clotting events (e.g. PE’s ,DVT, MI’s) Phase 3 trial Effective No change in mortality or morbidity Prothrombin Complex Concentrate (PCC) is preferred over rFVIIa.

13 Intracranial Hemorrhage Treatment
STICH II early surgery does not increase the rate of death or disability at 6 months small but clinically relevant survival advantage for patients with spontaneous superficial intracerebral hemorrhage without intraventricular hemorrhage. Mendelow, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trialLancet. Volume 382, Issue 9890, 3–9 August 2013, Pages 397–408.

14 Intracranial Hemorrhage Treatment
Minimally Invasive Surgery plus rt-PA for ICH Evacuation (MISTIE) Less peri-hematoma edema than control group Effective and safe clot removal Mould el al. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke Mar ;44(3):

15 Intracranial Hemorrhage: Blood Pressure
Too much pressure these vessels will burst or bleed more Need enough pressure for injured area to get blood from other vessels

16 Intracranial Hemorrhage: Current BP Guidelines
Class IIa Recommendation “In favor of” SBP 150 – 220 lower SBP to 140 Class IIb Recommendation “Less well established” SBP > 200 or MAP > 150 give IV infusion SBP > 180 or MAP > 130 ↑ICP monitor ICP, give intermittent or continuous IV medication SBP > 180 or MAP > 130 maintain BP 160/90 or MAP 110 with intermittent or continuous IV medication

17 Intracranial Hemorrhage: Blood Pressure Trial
Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) II Hypothesis: SBP reduction to ≤140 mm Hg reduces the likelihood of death or disability at 3 months after ICH Start IV nicardipine within 3 hours of onset of ICH and continue for 24 hours

18 Subarachnoid hemorrhage
Early aneurysm repair preferred Amicar Early, short course Avoid antifibrinolytic therapy > 48 post ictus or > 3 days, concern with side effects Screen for DVT while on

19 Vasospasm Monitor for delayed cerebral ischemia (DCI) in environment with expertise in SAH Give Nimodipine 60mg every 4 hours for 21 days Detect DCI with TCD, DSA, CTA, EEG, PbtO2

20 Comprehensive Stroke Center Primary Stroke Care Center
Move to Comprehensive, Multi-disciplinary and Multi-dimensional Stroke Care Advance Practice Nursing Critical Care Medicine Supporting Self Management NeuroIR, Physiatry, Therapist Vascular, Rehab, Stroke RNs NIR EVDs, tx of AVM, aSAH NSurg Program Management Leadership, Care Level Delivering/ Facilitating Clinical Care IV tPA Neuro Critical Care Comprehensive Stroke Center Access to SHC Primary Stroke Care Center Radiology Education to OSH Patient Outcomes Clinical Information Management Research Education/ info sharing Performance Improvement/ Measurement 8 metrics 26 metrics CSC specific resources Meaningful Use

21 ABCs of Stroke Airway Breathing Circulation Disability / DVT Education
Fever / Food Glycemic control Hypo / Hypertension Imaging

22 Airway Keep NPO until swallow screen performed Good oral care
Frasier Free Water protocol Good oral hygiene to prevent bacteria from going into lungs – silent aspiration This woman would not get swallow screen – facial droop – needs speech therapy

23 Breathing Lung sounds Oxygen saturation Shortness of breath
Use supplemental oxygen to keep SaO2 > 92% Shortness of breath

24 Circulation At least 2 IV sites
Use isotonic solution, not dextrose, for maintenance fluid Coumadin / warfarin Pradaxa/ Dabigatran 1. What is the goal INR for each? 2. What if the patient has a feeding tube?

25 Disability / DVT Neuro checks Early mobilization OOB Work with rehab
Frozen shoulder Sitting at edge of bed Verbal cues SCDs lovenox heparin

26 Education Diagnosis Interventions Signs of stroke, calling 911
Risk Factors

27 Risk Factors HTN Smoking Heart disease  cholesterol xs EtOH
Sedentary life style DM AF Prior stroke or TIA Age Sex Race Hereditary

28 Fever Treat fever aggressively Prevent infection
acetaminophen, ibuprofen Surface / intravascular cooling – avoid shivering Prevent infection Aspiration pneumonia Urinary tract infection

29 Food Oral intake Feeding tub or PEG Constipation Also consider:
Malnourished on admission? How long do we take to help feed? Enough calories?

30 Glycemic Control Blood sugar monitoring HgA1c How to control?
Avoid the lows!

31 Hypertension JNC 7 report. Journal of the American Medical Association. 2003;289:

32 What to do… Need Higher Need Lower
Low perfusion in brain - tight ICA, MCA Stroke not completed ***Does the neuro exam decline with decreased BP? Completed their stroke At risk of bleeding ***Slow and steady!

33 Imaging CT MRI TTE TEE

34 Stroke Certification for Nurses
Stroke Certified Registered Nurse (SCRN) ANVC Certification Exams (NVRN-BC) & (ANVP-BC) American Board of Neuroscience Nursing (ABNN) exam Through American Association of Neuroscience Nurses Neurovascular Registered Nurse - Board Certified Advanced Neurovascular Practitioner - Board Certified Through the Association of Neurovascular Clinicians (ANVC)

35 Guidelines Connolly ES Jr.., Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012;43:1711–37. Jauch EC, Saver JL, Adams HP Jr., Bruno A, Connors JJ, Demaerschalk BM, et al.; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947. Morgenstern LB, Hemphill JC 3rd., Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010;41:2108–29 Summers D, Leonard A, Wentworth D, Saver JL, Simpson J, Spilker JA, Hock N, Miller E, Mitchell PH. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke 2009; 40: 2911–44.

36 Questions?

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