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Acute Stroke Treatment 2017

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Presentation on theme: "Acute Stroke Treatment 2017"— Presentation transcript:

1 Acute Stroke Treatment 2017

2 Disclosure No financial or other relationship with any of the products, manufacturers or services discussed today.

3 Stroke Epidemiology Pathophysiology Incidence Prevalence Cost
80-90% of stroke is ischemic Incidence 795,000 strokes per year per CDC Prevalence 1 of every 15 people age 60 – 79 1 of every 6 people over age 80 Cost $34 Billion annually

4 Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360
Annual rate of all first-ever strokes by age, sex, and race (Greater Cincinnati/Northern Kentucky Stroke Study: 1999) Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360

5 Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360
Prevalence of stroke by age and sex (National Health and Nutrition Examination Survey: 2009–2012). Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360

6 Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360
Stroke Death Rates Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360

7 Pathophysiology of Cerebral Ischemia
Inadequate flow through cerebral vessels Due to Intrinsic disease of the affected vessel Thromboembolism Cardiac Extracranial vessel Decreased perfusion pressure Especially in the context of a flow-limiting stenosis

8 Pathophysiology of Cerebral Ischemia
Duration Transient (TIA) Transient focal CNS ischemia without infarction Seconds to minutes Prolonged (Infarction) Infarction Less than 2 to 3 hours Infarction of core More than 2 to 3 hours Infarction enlarges into penumbra

9 Ischemic Core and Penumbra

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12 Intrinsic Cerebrovascular Disease
Fluid Attenuation Inversion Recovery (FLAIR) Diffusion Restriction (DWI)

13 What Caused This Stroke?

14 Don’t Neglect the Right Hemisphere!

15 What Caused This Stroke?

16 The Brain is Complex

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18 Recognizing Stroke You don’t need to be a neurologist!
You do need to look for acute deficits characteristic of stroke: Language comprehension or fluency Dysarthria Vision Gaze / Eye Movement Abnormalities Visual Field Deficits Facial or Limb Weakness Limb or Gait Ataxia Lateralized Sensory Loss or Extinction Grading the deficits is of secondary importance

19 Stroke Mimics Syncope Hypoglycemia Seizure Migraine Aura
Transient Global Amnesia Encephalopathy Encephalitis Myelopathy

20 Stroke as a Cause of Death
Prior to 2008 3rd after Heart Disease and Cancer 2016 Heart disease Cancer Chronic Lower Respiratory Diseases Accidents Stroke -of-death.htm

21 Acute Stroke Treatment
December 1995: NINDS rtPA Stroke Trial 624 patients randomized rtPA vs. placebo 3 hour time window End point Complete or nearly complete recovery at 3 months Odds Ratio 1.9 with treatment “At least 30% more likely to have minimal or no disability at 3 months compared to placebo.” Tissue Plasminogen Activator for Acute Ischemic Stroke. N Engl J Med 1995;333:

22 The NIHSS Level of Consciousness Orientation Language Vision
Comprehension Fluency Vision Gaze Visual fields Facial weakness Dysarthria Limb weakness Limb ataxia Sensation Extinction (inattention)

23 NINDS Subgroup Analysis
Initial concerns that the apparent benefit from thrombolysis were an artifact of unequal severity of stroke between the two arms of treatment were not supported upon subsequent reanalysis of the NINDS data. The impact of imbalances in baseline stroke severity on outcome in the NINDS rtPA Stroke Study. Ann Emerg Med. 2005;45:

24 Subsequent Trials found Similar Efficacy
ECASS I ECASS II Atlantis A Atlantis B

25 Risk of Intracerebral Hemorrhage
NINDS 6.4% 45% were fatal 2.9% risk of fatal ICH No difference in mortality between groups 17% with thrombolysis vs. 21% placebo Tissue Plasminogen Activator for Acute Ischemic Stroke. N Engl J Med 1995;333:

26 Acute Stroke Treatment
2002: SITS-ISTR Safe Implementation of Thrombolysis in Stroke – International Stroke Thrombolysis Register 11,865 patients treated within 3 hours of onset 56% likelihood of Modified Rankin score of 0-2 Risk of early sICH: 1.6% (1.4 – 1.8) Guidelines for the Early Management of Patients with Acute Ischemic Stroke. Stroke March 2013 :

27 SITS-MOST 6483 patients in 285 European centers Rate of hemorrhage
Any hemorrhage (NINDS): 7.3% Include minor petechial change Symptomatic hemorrhage: 1.7% Increase in NIHSS of 4 points or more Thrombolysis with alteplase for acute ischaemic stroke: An observational study. Wahlgren N, et al. Lancet 2007 JAN 27;369(9558):

28 Acute Stroke Treatment
2014 Meta-Analysis 6756 subjects from numerous trials Treatment within 3 hours led to a good outcome (mRS 0-1) for 33% of patients versus 23% for controls. Benefit was similar regardless of Patient age Stroke severity Le coup de gras pour cette vieux echelle NIHSS ? Each 15-Minute reduction in time to treatment increases likelihood of discharge to home, ambulatory by 3 – 4 % Decreases risk of death and of ICH Effect of treatment delay, age and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual pateint data from randomised trials. Emberson J. et al. Lancet ;384(9958):1929.

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30 Earliest Possible Treatment is Important
Continuously improving likelihood (OR) for little or no neurological deficit (i. e. decreasing number to treat). Faster process may allow additional patients to be treated due to time window. Goal is DTN <60 minutes May change to 45 minutes Marler et al. Neurology. 2000;55:

31 J. K. 2100: 65 y/o male suddenly develops left-sided arm, leg and face weakness while getting ready for bed. Alerts wife who calls 911 immediately. 2112: Ambulance dispatched (L&S). 2130: Arrival on scene. Found to be awake, slurred speech, with left sided weakness and rightward gaze. 2148: Departure from scene. ACH notified of Code Stroke. IV access established, bloods drawn. 2212: Arrival at ACH

32 J. K. 2212: Arrival at ER 2222: CT Head is normal 2222: Seen by physician, moving arms and legs, but still with dysarthria, near-total left facial paresis, decreased sensation left side. (NIHSS =4) 2250: Telestroke initiated. 2353: tPA bolus administered -Onset to needle: 2:53 -Door to needle: 101 minutes 0024: Departure for MMC

33 Acute Stroke Treatment Components
Prehospital Transport Notification ED Assessment Imaging CT CTA Telestroke Assessment Informed Consent Mix and Administer tPA

34 Change in Paradigm With the advent of effective treatment comes challenge for the healthcare system: Management of a certain level of risk in order to achieve benefit Logistical Need for an accurate and detailed acute evaluation

35 T. K. 32 y/o mother of 3 who 27 weeks pregnant presents to ER approximately 90 minutes after onset of left sided weakness and confusion. Examination shows highly variable left sided weakness occasional rightward gaze variable left hemianopia normal vital signs CT scan is negative

36 T. K. Social History: Patient reports husband is about to fly a sortie in a B2 bomber out of Qatar. MRI is ordered.

37 T. K. MRI shows a small area of diffusion restriction in the right parietal lobe. CTA is ordered.

38 T. K. CTA shows proximal (M1 segment) right MCA occlusion, otherwise normal.

39 CT and MR Angiography

40 T. K. Patient is transported by helicopter to outside facility and brought directly to the cath lab, arriving 7 hours after onset of symptoms. Initial assessment at that time showed a decreased level of consciousness, rightward gaze, left hemianopia and left hemiplegia Initial angiographic images confirm a proximal right MCA thrombus with significant distal filling from collaterals

41 T. K. A catheter is passed through the thrombus with successful retrieval. Patient becomes more alert within 5 minutes, gaze normalizes and starts moving left side. Patient walks out of the hospital 2 days later to drive home with her husband, with no neurological deficits.

42 Thrombus Retrieval 5 studies in 2015 showed benefit for mechanical clot retrieval Meta-analysis 1287 patients OR for mRS 0-2 is 2.35 (CI 1.85 – 2.98) FDA approval for use within 8 hours of stroke onset Used typically after intravenous tPA Large vessel occlusion found on angiography Large ischemic penumbra

43 Mechanical Thrombectomy
Acute ischemic stroke with NIHSS of at least 2 ASPECTS score of at least 6 Proximal Arterial occlusion on CTA or MRA ICA MCA (M1 / M2) ACA (A1 / A2)

44 Mechanical Thrombectomy
Superior to IV thrombolyis alone Odds ratio 2.35 (95% CI ) Number to treat for little or no neurological deficit: 4 Is ordinarily used as an adjunct to IV thrombolysis Can also be used in patients who are not candidates for IV thrombolysis Time to treat of 6 hours – longer in selected cases Location Extent of tissue at risk Effectiveness of collateral recruitment Therapeutic anticoagulation

45 Acute Stroke Management
Blood Pressure Management Goal < 185/110: Prethrombolysis < 180/105: Thrombolysis (x 24 hours) < 220/120: Post Stroke Permissive Hypertension Method Acute Labetolol Nicardipine drip Avoid hydralazine, nitroglycerin, nifedipine! Subacute OK to reintroduce baseline antihypertensives after hours if Neurologically stable Large vessel occlusion has been ruled out Maintain Euvolemia Isotonic saline without dextrose Maintain glucose 60 to 180 mg/dl Avoid Fever Dysphagia screening Nutrition within 48 hours is important

46 Identify and Treat the Pathophysiology
Imaging MRI Confirmation of infarction Hints as to pathophysiology Angiography MRA CTA Carotid US Poor assessment of the vertebral arteries Can miss carotid and vertebral artery dissection

47 Cryptogenic Stroke 30 - 40% of all ischemic stroke Consider
Cardiac source of embolus PAF ASD Hypercoagulable state Less than age 50 Past or family history of thrombotic events

48 Identify and Treat the Pathophysiology
Echocardiography Consider ASD Saline contrast Doppler Consider TEE if high index of suspicion for cardiac source Telemetry Cardiac event loop monitor for ?PAF 30 days to 3 years

49 Initiate Secondary Prevention Strategies
Antithrombotic Therapy Antiplatelet therapy Aspirin Aspirin with long-acting dipyridamole (Aggrenox) Clopidogrel (Plavix) Anticoagulation Indicated for some cardiac sources of emboli Atrial fibrillation, including PAF Agents Coumadin NOAC

50 Initiate Secondary Prevention Strategies
Blood Pressure Control Lipid Management Check an admitting LDL Start a statin if possible Target LDL Diabetes Management Target A1C of 7.0 to 8.0 Smoking Cessation!

51 The Bottom Line Ischemic stroke is a leading cause of death and disability Acute and subsequent treatment of stroke must address underlying pathopysiology Stroke is not difficult to recognize: a sudden development of a focal neurological deficit Incidence and severity are impacted significantly by current management practices Hyper acute management Acute management Primary and secondary prevention


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