1. Hemiparesis: The Emerging Role of the Emergency Physician in Stroke Management Edward Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois College of Medicine-Chicago Chicago, IL

2. Edward Sloan, MD, MPH Objectives Present clinical case history Review Emergency Department H&P Examine tPA clinical data Discuss tPA use in ischemic stroke Review other therapies for ischemic stroke Answer clinically relevant questions

3. Edward Sloan, MD, MPH Case A 70 year old female developed acute onset of left arm weakness that lasted approximately 15 minutes and then gradually resolved. She chose to ignore the event and did well until three weeks later she developed complete paralysis of the left arm and pronounced weakness of the left leg; neither resolved and approximately 90 minutes into the event she called EMS. Past medical history included hypertension and COPD. Medications: metoprolol, hydrochlorthiazide, and atrovent.

4. Edward Sloan, MD, MPH Case On exam, BP 200/120, P 68, RR 18, T 98, and pulse oximetry showed 94% saturation. The patient appeared alert though responses were slow. The patient had bilateral carotid bruits, clear lungs, and a regular rate and rhythm. There was no facial asymmetry, upper extremity motor 5/5 on the right and 0/5 on the left; lower extremity motor 5/5 on the right and 3/5 on the left. Sensory was intact to light touch and pinprick. DTRs were 2/2 on the left and 0/2 on the right. Planter reflex was downgoing on the right and upgoing on the left.

5. Edward Sloan, MD, MPH Acute Ischemic Stroke Questions What are the epidemiology & etiology? What are the key elements of the exam? What is the NIH stroke scale? What did the NINDS trial show? How should tPA be used by the EM MD? What about hemorrhagic conversion? What about other therapies?

6. Edward Sloan, MD, MPH Acute Stroke: Epidemiology 700,000 Cases annually 20% mortality within one year $30 billion annual costs Ischemic and hemorrhagic strokes

7. Edward Sloan, MD, MPH Acute Ischemic Stroke: Etiology Thrombotic, embolic, hypoperfusion Majority are vessel thrombosis Clot formation on diseased vessel 20% are embolic, from heart, great vessels Hypoperfusion with cardiogenic shock

8. Edward Sloan, MD, MPH Acute Ischemic Stroke: Syndromes Anterior cerebral Middle cerebral Posterior cerebral Vertebrobasilar Basilar artery occlusion Cerebellar Lacunar Arterial dissection

9. Edward Sloan, MD, MPH Acute Stroke: Historical Elements When did symptoms begin? Onset? Prior history of similar symptoms? When was the patient last seen normal? Risk factors? Medical hx that would preclude tPA use?

10. Edward Sloan, MD, MPH Acute Stroke: Physical Exam Vital signs, pulse ox, accucheck HEENT: Pupils, papilledema, airway Neck: Bruits, nuchal rigidity Chest: Rales (CHF, aspiration) Cardiac: Gallops, murmurs

11. Edward Sloan, MD, MPH Acute Stroke: Physical Exam Abd: Evidence of AAA Ext: Evidence of CHF, DVT Skin: Evidence of infectious etiology Neuro: CN, motor, sensory, reflexes, cerebellar, visual, language, neglect, mental status

12. Edward Sloan, MD, MPH Neurologic Exam: Cranial Nerves CN: Anterior vs. brainstem? – Anterior: Contralateral CN deficits – Brainstem: Ipsilateral CN deficits

13. Edward Sloan, MD, MPH Neurologic Exam: Motor Motor: CN, upper & lower ext – CN: Eye motor (Bell’s) – Upper: Pronator drift – Lower: Leg lift

14. Edward Sloan, MD, MPH Neurologic Exam: Sensory Sensory: Light touch, pinprick Graphesthesia

15. Edward Sloan, MD, MPH Neurologic Exam: Reflexes Normal vs. pathologic – Normal: Corneal, gag, DTRs – Pathologic: Babinski, Chadduck

16. Edward Sloan, MD, MPH Neurologic Exam: Cerebellar Truncal ataxia Ataxic gait Rhomberg

17. Edward Sloan, MD, MPH Neurologic Exam: Visual Visual field deficit Homonomous hemianopsia – Neglect of one side

18. Edward Sloan, MD, MPH Neurologic Exam: Language Dysarthria: Poor speech, motor dysfunction Aphasia: Disturbed language processing – Expressive: can’t speak – Receptive: can’t process the spoken word

19. Edward Sloan, MD, MPH Neurologic Exam: Mental Status Level of consciousness (AVPU) – Alert – Responds to verbal – Responds to painful – Unresponsive

20. Edward Sloan, MD, MPH Neurologic Exam: NIH Stroke Scale 13 item scoring system, 7 minute exam Integrates neurologic exam components CN, motor, sensory, cerebellar, visual, language, LOC Maximum score is 31, signifying severe stroke Minimum score is 0, a normal exam Scores greater than 15-20 are more severe

21. Edward Sloan, MD, MPH Acute Ischemic Stroke: NINDS Clinical Trial of tPA Treatment within 180 minutes 0.9 mg/kg of tPA Two part study Endpoint: favorable outcome at 3 months Also examined mortality, hemorrhage

22. Edward Sloan, MD, MPH NINDS Clinical Trial of tPA: Results Good outcome: 30% more patients Odds of favorable outcome: 1.7 (1.2-2.6) 10x greater hemorrhage risk: (6.4 vs. 0.6%) Comparable 3 month mortality: (17 vs. 21%) Conclusion: tPA worth the hemorrhage risk, since there is clear benefit

23. Edward Sloan, MD, MPH NINDS Clinical Trial of tPA: Clinical Upshot tPA must be considered Patient selection is very difficult Must maximize risk/benefit ratio Must avoid hemorrhage, if possible Need adequate severity, but not too severe Less than 2% of patients will meet criteria

24. Edward Sloan, MD, MPH NINDS Clinical Trial of tPA: Timing Issues Early EMS contact is key Door to CT and CT read time important Is there time for a neurologist to consult? A stroke team helps The 3 hour window is not the only issue

25. Edward Sloan, MD, MPH NINDS Clinical Trial of tPA: Clinically Relevant Issues Histories are unreliable Timing issues hard to press for stroke Patient selection is painfully difficult Every CT has a hypodense area Tendency not to intervene First do no harm What we did vs. what was destined to be

26. Edward Sloan, MD, MPH tPA in Acute Ischemic Stroke: Clinical & Documentation Issues Document that tPA was considered If not used, state explicitly why the pt did not meet criteria or why it was deferred When explaining, tell the four key points: – 30% greater chance of good outcome – 10 fold greater risk of bleeding – Same mortality rate, despite bleeding risk – Explain why mortality is comparable

27. Edward Sloan, MD, MPH tPA in Acute Ischemic Stroke: Other Relevant Studies ECASS: No efficacy, higher mortality IA tPA: Effective, feasible ATLANTIS: 5 hour window not possible Cleveland: Non-supportive tPA data – 2% treated, 50% standard of care deviation – 16% bled, 3x higher in-hospital mortality STARS: Favorable outcome and mortality

28. Edward Sloan, MD, MPH Acute Ischemic Stroke: Goals of Other Therapies Recanalization Stop ischemic cascade Minimize hemorrhage Minimize morbidity and mortality

29. Edward Sloan, MD, MPH Acute Ischemic Stroke: Other Therapies LMW heparin: Possibly effective IST study: ASA reduces death & stroke recurrence by 1% PROACT II: IA prourokinase improves outcome STAT: Ancrod (pit viper venom) improves outcome, but causes hemorrhage Neuroprotectants: May provide benefit

30. Edward Sloan, MD, MPH Acute Ischemic Stroke: Other Issues MR Imaging: Feasible, assists pt selection Admission need: Still must admit TIA/CVA pts – No reason not to admit CVAs – Can’t predict progression, complications – Data less clear for TIAs…home observation? – Need HMO experience to be documented

31. Edward Sloan, MD, MPH Acute Ischemic Stroke: Case Management Get the CT scan ASAP Control the blood pressure Start making calls: PMD, family, neurologist Find out the CT results Decide risk/benefit Discuss with pertinent decision makers

32. Edward Sloan, MD, MPH Acute Ischemic Stroke: Specific Case Outcome CT obtained quickly BP controlled with time & SL NTG NIH stroke scale: 15 CT showed ?? Low density area Neurologist not inclined to treat Family defers tPA after consultation Some long term deficit, physical therapy

33. Edward Sloan, MD, MPH Acute Ischemic Stroke: Conclusions Ischemic stroke is a big problem There is significant morbidity & mortality tPA is effective in a narrowly defined group Must aggressively work to get tPA used Other therapies hold promise

34. Edward Sloan, MD, MPH Acute Ischemic Stroke: Recommendations Better public education More timely EMS activation More analysis of tPA use re: optimal patients Rapid MR imaging Dvlp other therapies, esp neuroprotectants

35. Edward Sloan, MD, MPH All are true statement about acute ischemic stroke except: a. There are three major categories: thrombotic, embolic, and hypoperfusion. b. The majority of all strokes are caused by vessel thrombosis. c. The symptoms of ischemic stroke develop over minutes to hours. d. The most common source of emboli are the heart and major vessels. e. Middle cerebral artery infarction is associated with ipsilateral weakness and numbness.