1. Neuroscience Telemedicine Orientation
Nancy Turner, BSN, RN, CPAN
Neuroscience Telehealth Coordinator
David Jones, BSN, RN, CCRN, SCRN, CSRN

2. Telestroke

3. Stroke Statistics
Leading cause of serious long term disability in the U.S.
5th leading cause of death – 1 American dies every 4 minutes1
Costs $36.5 billion annually – lost productivity and treatment2
130,000 Deaths each year - 1 in every 20 deaths.1
>795,000 people in the US have a stroke.
610,000 are first or new strokes.
1 in 4 are recurrent strokes.2
1 Kochanek KD et al. National Vital Statistics Reports. 2011;60(3).
2. Roger VL et al. Circulation. 2012;125(1):e2–220.

4. Stroke Statistics SC is located in the buckle of the stroke belt
Highest and second highest stroke mortality rate in U.S. ( )
For , SC has the 4th highest stroke mortality rate in the U.S.
Stroke is the 3rd leading cause of death in South Carolina; although it is the 5th leading cause in North America

5. Translation In one minute 1.9 million neurons are lost
14 billion synapses are lost
12 kilometers of myelinated fibers are lost
Saver, J. Time is Brain – Quantified. Stroke Jan;37(1):263-6.

6. Translation 30 minutes = 10%!
30 min delay = an absolute 10% decrease in patient outcomes
(Khatri. Neurology, 2009) 6

7. What is a Stroke? A Stroke is a “Brain Attack”
The brain is suddenly deprived of blood flow and consequently, oxygen.
Like STEMI’s and Traumas, stroke response is a team sport.
It is thusly named a “Brain Attack Team” or BAT for short at MUSC*
*Names will vary among differing agencies

8. Types of Stroke Ischemic Hemorrhagic
Loss of or significant reduction of blood flow to brain tissue
Expulsion of blood products out of the vascular space and into the tissue or tissue spaces of the brain
Comprises 80% of all strokes
Comprises 20% of all strokes

9. Neuro-Anatomy

10. Neurovascular Anatomy

11. Stroke Deficit Vocabulary
Apraxia – impaired planning and sequencing of movement despite having the strength and coordinating to complete the task
Ataxia – impaired coordination
Aphasia – loss of comprehension or expression of language
Dysphagia – difficulty swallowing
Dysarthria – slurring of speech without loss of language
Plegia – inability to activate any motor neurons. Paralysis
Paresis – reduced ability to activate motor neurons causing weakness
Extinction (to double simultaneous stimulation) – in ability to recognize that two stimuli are being presented at once
(Hemispatial) Neglect - inability to process or perceive stimuli from one direction or features of one side of the body

12. Warning Signs of Stroke
Sudden onset of any symptoms listed below:
Impaired sensation or control of the face, arm or leg
Confusion, impaired speech or ability to understand
Impaired vision, gait, balance or coordination
Severe headache, or neck pain

13. Ischemic Stroke S/S - Anterior
Left Hemisphere
Left gaze preference (eyes deviated to left)
Right visual field loss
Right-sided weakness
Right-sided sensory changes
Aphasia
Right Hemisphere
Right gaze preference (eyes deviated to right)
Left visual field loss
Left-sided weakness
Left-sided sensory changes
Left hemi-inattention (neglect)

14. Ischemic Stroke S/S - Posterior
Brainstem or Cerebellum
Nausea and/or vomiting
Double vision
Abnormal eye movements
Difficulty swallowing
Vertigo
Weakness on one side of the body or in all limbs
Sensory loss on one side of the body or in all limbs
Decreased consciousness
Unsteady gait
Limb ataxia

15. Hemorrhagic Stroke S/S
Subarachnoid hemorrhages (SAH) occur on the outside of the brain.
Intra-cerebral hemorrhage (ICH) occur in the brain tissue itself.
S/S Include:
Focal neurological deficits as in AIS
Headache (especially in subarachnoid hemorrhage)
Neck pain
Light intolerance
Nausea, vomiting
Decreased level of consciousness
Copyright © 2012 University of Washington

16. The Penumbra Hypoperfused brain tissue Has capacity to recover
Only if perfusion is restored!
Metabolically active
Astrup et al., 1981

17. Role of EMS Staff: Pre-Hospital
Early Recognition is Key!
If the signs are missed, time will slip by and the opportunity to treat will be lost forever.
Minimal scene time
ABC’s, Neuro Assessment, LKN, Medications, & Hx., Family Cell #
IV Access
2 Large Bore IV’s
Antecubital Vein for perfusion scanning
FSBS
Rapid Transport
Early encoding to ED

18. What a Stroke Response Should Look Like
The Stroke Team
EMS
ED Physicians
ED Nursing Staff
Stroke MD (In-House and/or Telemedicine)
CT Technologist
Pharmacy
Phlebotomy (If used in ED setting)
The Goals
Door to Needle/t-PA: 60 min
CT Interpreted: 45 min
Door to CT Scan: 25 min
Door to Stroke MD: 15 min
Door to ED MD: 10 min
REMEMBER:
IF YOU USE THE FULL 60 MIN;
THE PATIENT JUST LOST 120 MILLION NEURONS
AHA/ASA Target: Stroke Measures

19. What a Stroke Response Should Look Like
Code Stroke CT
tech
CT scan
Nurse #1
IV placement, lab draw
Vital sign monitoring
Weight estimate
Assist with exam ED
physician
Obtain History
Meds/allergies
Review chart for previous visits
Order tPA
Nurse #2
Activate telemedicine system
Verify time of onset with witnesses
Find ancillary info
Mix tPA ED
tech
Emergent
transport of
bloods to lab
Admitting
Patient ID
Registration
Room assign
Decision
Bolus & Infuse tPA

20. It is simple Stroke Care in 2016 Do it fast Do it safely
Do it as a team

21. tPA Myth vs. Fact
Alteplase(tPA) is Standard of Care for Ischemic Stroke since 1996
NO SUBSTITUTIONS! (TNK)
*Greater chance of litigation for not using vs. using and having a bad outcome
Genentech will replace any opened but unused Alteplase no questions asked; so don’t hesitate to mix it!
*Liang and Zivin, 2008

22. tPA: Inclusion vs. Exclusion
Significant head trauma or prior stroke in the previous 3 mo.
Symptoms suggest SAH
Arterial puncture at noncompressible site in previous 7 d
History of previous intracranial hemorrhage
Intracranial neoplasm, AVM, or aneurysm
Recent intracranial or intraspinal surgery
Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
Active internal bleeding
Acute bleeding diathesis, including but not limited to
Platelet count < /mm3
Heparin received within 48 h resulting in abnormally elevated aPTT above the upper limit of normal
Current use of anticoagulant with INR >1.7 or PT >15 s
Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (eg, aPTT, INR, platelet count, ECT, TT, or appropriate factor Xa activity assays)
Blood glucose concentration <50 mg/dL (2.7 mmol/L)
CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
Inclusion
>18 years old
Diagnosed Ischemic Stroke with disabling neurological deficit
Non-contrast CT head scan that does not demonstrate any hemorrhage, tumor, or mass effect; Essentially normal CT.

23. tPA: Relative Exclusion
Recent experience suggests that under some circumstances, with careful consideration and weighting of risk to benefit, patients may receive fibrinolytic therapy despite ≥1 relative contraindications.
Consider risk to benefit of intravenous tPA administration carefully if any of these relative contraindications is present:
Only minor or rapidly improving stroke symptoms (clearing spontaneously)
Pregnancy
Seizure at onset with postictal residual neurological impairments
Major surgery or serious trauma within previous 14 days
Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
Recent acute myocardial infarction (within previous 3 months)

24. Pre-tPA Management Diagnose Ischemic Stroke
Prepare Alteplase Bolus & Infusion
Reduce blood pressure to <185 Systolic and <110 Diastolic before administration
Drugs of choice: Labetalol if HR > 70, Hydralazine, or Cardene Drip
Maintain SBP of <180 & DBP <105 for the following 24 hours
If patient will tolerate it: Keep HOB less than 30o to flat if possible!

25. During & Post tPA Infusion Management
Maintain SBP < 180 & DBP <105 for 24 hours after bolus
Check V/S & Complete NIHSS
Q15 min x2 hours; Q30 min x6 hours; Q1 x16 hours from time of tPA Bolus
Monitor for S/S of hemorrhagic transformation
Sudden worsening of LOC and/or NIHSS
Sudden onset headache, nausea, and/or vomiting
Monitor for adverse reactions
Angioedema
Other new onset bleeding
Remember that the greatest chance for bleeding is in the first 24 hours!

26. Management of Bleeding
STOP INFUSION IMMEDIATELY if S/S of hemorrhagic transformation or any adverse reaction is noted
Send for STAT head CT to R/O ICH
Send STAT Hgb/Hct, Plt, PT, PTT, Fibrinogen
Transfuse
PRBC Type & Cross x4 Units
Cryoprecipitate 4-6 Units
Consult Neurosurgery
If no in-house Neurosurgery, Prep for transfer to nearest appropriate facility

27. Thrombectomy: The new Gold Standard in Ischemic Stroke treatment
Thrombectomy is the intra-arterial revascularization of an occluded vessel; A.K.A –
The ESCAPE trial showed that 53% of patients who received thrombectomy had a mRS of 0-2 at 90 days
There were several trials being conducted on thrombectomy, all of which showed a 50% improvement in outcome for reaching a mRS of <2
Number Needed to Treat (NNT) = 4
There are a variety of techniques and devices available to perform thrombectomy

28. Role of EMS Inter-hospital Transport
Potential thrombectomy patients should always be transferred by air whenever possible
TIME IS BRAIN – 1.9 Million Neurons lost per minute
Stroke patients that are transferred to MUSC should have the EMS Flowsheet filled out.
Sending ED Nursing staff fills out the demographics & tPA information
EMS must document the vitals & neuro exam per the recommended time intervals

29. Role of EMS Inter-hospital Transport
As before, it is imperative to maintain an acceptable blood pressure
Keep all tPA patients below 180 SBP and 105 DBP
Don’t bottom them out!
Permissive HTN is acceptable, in non-tPA patients
<220 SBP
Place the HOB 30o to flat IF they can tolerate it
Stroke patients can be very susceptible to changes in position
Cerebral collateral circulation can be improved in the flat or head down position; providing vital blood flow to the affected brain tissue

30. QUESTIONS? ?

31. Teleneurology & Tele-EEG

32. What is Teleneurology
Many small hospitals do not have the population base necessary to support access to local neurologists around the clock
Expands on the well-established Telestroke program at MUSC
Scheduled and urgent teleconsultation services
Additionally, allows for the appropriate determination of the need for transfer to MUSC Health
Helps keep the patient within their own support system in their community.

33. What is TeleEEG
This test is essential in providing accurate determinations of brainwave activity, particularly to help diagnose epilepsy
Local hospitals may have the ability to perform an EEG, but are not able to keep a specially trained neurophysiologist on staff
Delays diagnosis and treatment
Complementary service to MUSC Health’s Tele-Neurology program
Or as a stand-alone service
Tele-EEG program provides specially-trained neurophysiologists seven days a week for the interpretation of both routine and urgent EEGs.

34. Teleneurology process
Patient with Neurologic signs/symptoms presents to your facility/service
AMS, focal weakness, seizures, headache, multiple sclerosis, etc…
Determine severity of condition for acute vs. scheduled consult
Status or uncontrolled seizure vs. stable headache
Call MUSC ATC and request a Neuro Consult
Specify if request is for acute or scheduled
Acute consults will be joined within 30 min
Scheduled appointment times are currently in the afternoon hours only
Scheduled consults will be joined within 24 hours

35. Teleneurology Process: Acute vs. Scheduled Neurology Consults
Neurology Consult All Neurological conditions EXCEPT STROKE!!
Call MUSC Neuro
Acute Consults
(30 min. response)
Scheduled Consults
Non-Acute (<24hr. Response)
All other neurology needs including non-acute stroke, TIA, post t-PA consult, AMS, seizure, etc…
Uncontrolled Seizure or Status Epilepticus

36. Initiating a Teleneurology Consult
As a MUSC Health Telestroke partner site, you should already have a cart onsite for Telestroke calls that can be utilized for the Teleneurology service as well.
Sites with large enough volume to warrant it, additional carts will be arranged
Carts are supplied based on actual and expected consult volumes
This is variable from site to site
Teleneurology consults can be conducted in any area of the hospital with adequate internet access
This includes the emergency room, inpatient floors, and even the PACU if you have boarders

37. Quick Start Reference
Technical Support:
Starting a Consult:
Position the cart at the end of the bed, about 3-5 feet from the foot of the bed so that the camera can be focused on the patient. PLEASE DO NOT TOUCH THE CAMERA
Turn on the REACH system by moving the mouse
Double click on the REACH icon
Login using your specific username and password
Enter New Patient information: Name, Gender, Room #
Select appropriate template and give reason for consult – click SUBMIT
Once in consult, please enter the following important information:
Treating physician name
RN name
*Last Known Well
Date of admission or Time in the ED
Vital Signs (including weight)
Pertinent diagnostic test results including labs, EEG, and imaging results
Brief history and any notable exam findings
Family Contact name & phone #
MUSC consultant will complete Neurologic assessment with RN assistance

38. Why to Call
Teleneurology Consults can be made for a variety of conditions/symptoms:
Headaches, head pain
Migraines (chronic, acute, or complex), Cluster headaches
Trigeminal neuralgia
Seizures
Acute, chronic, status, or uncontrolled
Progressive neurologic deficits, Bell’s Palsy, Radial nerve palsy
Encephalopathies, confusion, and coma
Diffuse weakness, paraplegia, or gait disturbance
Dizziness/vertigo
Syncope
Unusual movement disorders

39. QUESTIONS? ?

40. Tele-presenting: Assisted assessment through telemedicine

41. Focuses on impairment of function
Why NIHSS:
Focuses on impairment of function
Consistent manner for exam between providers
Easily communicated and understood
Replicable
EMS ER
ICU
Stroke Unit

42. NIHSS : Do the scale in the order listed.
Do not skip items because you assume you know the answer.
Do not go back and change scores.
Scores should reflect what the patient does, not what you think the patient can do.
Record scores while administering the exam.
Do not coach the patient.
Work quickly.
Each assessment is a snapshot of the patient at that moment.

43. 1a. Level of Consciousness
Assess by greeting the patient, introducing yourself, and asking simple questions. “How are you feeling?” “Do you have any pain?” Scoring: 0 – Alert, answers readily and appears to comprehend 1 – Arousable by minor stimulation, examiner must repeat the question because the patient doesn’t appear to understand, or touch the patient to stimulate the patient. 2 – Arousable by repeated or strong stimulation 3 – Unresponsive or reflex responses only

44. 1b Level of Consciousness Questions
Assess the ability to comprehend and answer questions:
“What month is it?”
“How old are you?”
*Remember do not coach the patient to achieve the answer*
Scoring:
0 – Answers both questions correctly
1 – Answers one question correctly
2 – Answers neither question correctly
*If patient can not speak, then ask if they can write, if so provide pen and paper. Spoken and written answers score the same. Misspelling should be ignored as long and the writing can be understood.*

45. 1c Level of Consciousness Commands
Assess patient’s ability to follow simple commands:
“Open your eyes wide then close them tight.”
“Make a tight fist then open it.”
Make sure the patient is focusing on you and what you want them to do, it is OK to demonstrate to the patient what you want them to do.
Scoring:
0 – Performs both task correctly
1 – Performs one task correctly
2 – Performs neither task correctly
*Remember to score the patient’s first attempt*

46. 2 Best Gaze
Done to evaluate the horizontal movement of the eyes. Tested by asking the patient to follow a finger with their eyes, or you can ask the less alert patient to look at your face then move from one side of the patient to the other. Scoring: 0 – Normal 1 – Partial gaze palsy: gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present 2 – Forced deviation: total gaze paresis not overcome by the oculocephalic maneuver.

47. Hemianopia: decreased vision or blindness in half of the visual field
Assessing visual fields by confrontation, using finger counting or visual threat.
Scoring:
0 – No visual loss
1 – Partial hemianopia
2 – Complete hemianopia
3 – Bilateral hemianopia, or blind patient
Hemianopia: decreased vision or blindness in half of the visual field
**Note for the Telepresenter:
Share the same visual field as the patient
If they have a right gaze – get down on the right side to look them in the eye
Use 1 or 2 fingers ONLY!!

48. 4 Facial Palsy
Assess by asking or pantomime to encourage patient to: “Show me your their teeth” “Raise your eyebrows” “Close your eyes” Scoring: 0 – Normal (symmetrical movements) 1 – Minor paralysis (flattened nasolabial fold, asymmetry on smiling). 2 – partial paralysis (total or near total paralysis of lower face) 3 – Complete paralysis one or both sides (absence of facial movement in the upper and lower face)

49. 5 Motor Arm (5a-left arm, 5b-right arm)
Assess the ability to hold the arm in a stable position without drifting. Position limb palm side down at least 45 degrees from body and count out loud for 10 seconds will monitoring for a drift. Each limb is scored separately. Scoring: 0 – No drift 1 – Drift (drifts down but does not hit bed or other support) 2 – Some effort against gravity (limb can not get to or maintain position, but has some effort against gravity) 3 – No effort against gravity (limb falls) 4 – No movement UN – Amputation or joint fusion

50. 6 Motor leg (6a-left leg 6b-right leg)
Assess the ability to hold the leg in a stable position without drifting. Position limb at least 30 degrees from body and count out loud for 5 seconds will monitoring for a drift. Each limb is scored separately. Scoring: 0 – No drift 1 – Drift (drifts down but does not hit bed or other support) 2 – Some effort against gravity (limb can not get to or maintain position, but has some effort against gravity) 3 – No effort against gravity (limb falls) 4 – No movement UN – Amputation or joint fusion

51. Finger – nose – finger test
7 Limb Ataxia
Assesses muscle control and coordination, while differentiating these from general weakness.
Finger – nose – finger test
Heel – shin test
Scoring:
0 – Absent
1 – Present in one limb
2 – Present in two limbs
UN – Amputation or joint fusion
*If patient can not perform task because of coma, paralysis, or lack of ability to understand direction, then the score is 0*

52. 8 Sensory Assess sensation or grimace to pinprick.
Use the pointed end of a Q-tip, gently prick patient on face with eyes open; do you feel this? Does it feel the same on each side?
Repeat on inner forearms and inner lower leg.
Scoring
0 – Normal, no sensory loss.
1 – Mild to moderate sensory loss, patient feels pinprick is dull on the affected side, or there is loss of superficial pain with pinprick but patient is aware of being touched.
2 – Severe to total sensory loss, patient not aware of being touched.
**Note for the Telepresenter:
This is a Sharp-Dull exercise; DO NOT use light touch
Take one of the long Q-Tip applicators and break the stick to use the pointed end

53. 9 Best Language
Assess by asking the patient to describe what is happening in the attached picture, name the items, and to read from the standard list of words/sentences Make sure the if the patient wears glasses that they are on. Scoring 0 – No aphasia, normal 1 – Mild to moderate aphasia, some obvious loss of fluency or facility of comprehension. 2 – Severe aphasia, all communication is fragmented 3 – Mute, global aphasia

54. What do you see happening in this picture?

55. What is this? Point to each item individually
**Note for the Telepresenter:
Remember the consultant may be unable to hear the patient response. Rely as needed

56. Read the sentences:
You know how. Down to earth. I got home from work. Near the table in the dining room. They heard him speak on the radio last night.

57. 10. Dysarthria
Assess by asking the patient to read the attached list, or have them repeat back to you. Scoring 0 - Normal 1 - Mild to moderate dysarthria, patient slurs at least some words but, can be understood 2 - Severe dysarthria; patient is either mute or speech is so slurred they cannot be understood out of proportion to any dysphagia that is present. UN - intubated or other physical barriers

58. Say the words: MAMA TIP – TOP FIFTY – FIFTY THANKS HUCKLEBERRY
BASEBALL PLAYER

59. 11 Extinction and Inattention
Sufficient information to identify neglect may be obtained during the prior testing (Sensory or visual fields).
Scoring
0 – No abnormality
1 – Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities.
2 – Profound hemi-inattention or extinction to more than one sensory modality.
**Note for the Telepresenter:
When checking visual fields, remember to check simultaneous bi-lateral vision
Pt. may visualize each side individually but not simultaneously
This also applies to sensory; remember to check simultaneous bi-lateral sensation
The Pt. may feel each side individually but not simultaneously

60. NIHSS Scoring:
Total scores range from 0-42 with higher values representing more severe infarcts
> Very severe neurological impairment
Severe impairment
Moderately severe impairment
< Mild impairment
Adams, HP, et al. (1999). Neurology: 53:
A 2-point (or greater) increase on the NIHSS administered serially indicates stroke progression. It is advisable to report this increase.

61. Online NIHSS Certification
Online NIHSS Certification available free through the American Stroke Association.
The online program provides detailed instructions and demonstration scenarios for practice in scoring the NIHSS.
Certification is completed by scoring different patient scenarios.

62. QUESTIONS? ?