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Transcript of STROKE Presented by Robert Nelson BSN, MBA, MHA, SCRN, CNRN, ONC Vice President Neuroscience and...
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STROKE
STROKE
Presented by Robert Nelson BSN, MBA, MHA, SCRN, CNRN, ONC
Vice President Neuroscience and OrthopedicsHCA East Florida Division
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OBJECTIVESOBJECTIVES
Discuss the Risk Factors for Ischemic Stroke
Define two types of stroke ischemic and hemorrhagic
Discuss the Evaluation and Work-up for Ischemic Stroke
including Potential Thrombolytic Candidates
Identify eligible stroke patients for thrombolytic therapy
Identify the Primary steps in the management of Stroke
Secondary prevention of stroke.
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Stroke Epidemiology and Risk Factors
Stroke Epidemiology and Risk Factors
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StrokeStroke
Stroke is an acute vascular event that affects the brain.
Stroke involves neurological changes caused by an acute interruption of blood supply to a part of the brain.
There are two main types of stroke. The first type is ischemic stroke, which
results from decreased blood flow to a portion of the brain with consequent cell death.
The second type is hemorrhagic stroke, which results from bleeding within the brain.
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Stroke FactsStroke FactsStroke FactsStroke FactsA leading cause of death in the United States
795,000 Americans suffer strokes each year
134,000 deaths each year- From 1996 to 2006, the stroke death rate fell 33.5% and number of deaths fell by 18.4%
6,400,000 stroke survivors
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Stroke FactsStroke FactsStroke FactsStroke Facts
A leading cause of adult disability
Up to 80% of all strokes are preventable through risk factor management
On average, someone suffers a stroke every 40 seconds in America
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Non-modifiable Risk Factors
Non-modifiable Risk Factors
Age
Gender
Race/ethnicity
Heredity
Sacco RL, et al. Stroke. 1997;28:1507-1517.
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Women & StrokeWomen & StrokeWomen & StrokeWomen & Stroke
Stroke kills more than twice as many American women every year as breast cancer
More women than men die from stroke and risk is higher for women due to higher life expectancy
Women suffer greater disability after stroke then men
Women ages 45 to 54 are experiencing a stroke surge, mainly due to increased risk factors and lack of prevention knowledge
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African Americans & StrokeAfrican Americans & StrokeAfrican Americans & StrokeAfrican Americans & Stroke Incidence is nearly double that of Caucasians
African Americans suffer more extensive physical impairments
Twice as likely to die from stroke than Caucasians
High incidence of risk factors for stroke Hypertension Diabetes Obesity Smoking Sickle cell anemia
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Hispanics & StrokeHispanics & StrokeHispanics & StrokeHispanics & Stroke
Higher incidence among Mexican Americans than Caucasians
Mexican Americans are at increased risk for all types of stroke and TIA at younger ages than Caucasians
Spanish-speaking Hispanics are less likely to know stroke symptoms than English-speaking Hispanics, African Americans and Caucasians
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Stroke Risk Factors:Modifiable/LifestyleStroke Risk Factors:Modifiable/Lifestyle
Hypertension
Cigarette smoking
Hypercholesterolemia
Hyperlipidemia
Excessive alcohol use
Cocaine and IV drug use
Physical inactivity
Oral contraceptive use
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Potentially Treatable or Modifiable
Risk Factors for Stroke
Potentially Treatable or Modifiable
Risk Factors for Stroke Heart disease (MI,
CHF, PFO)
Atrial fibrillation
Prior stroke or TIA
Carotid artery disease
Sickle cell anemia
High RBC count
Diabetes
Menopause
Obesity
Elevated homocysteine level
Low socioeconomic status
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Management of Patients with Ischemic Stroke
Management of Patients with Ischemic Stroke
Stabilize the patient - A B C’s
Restore or Improve Blood Flow
Thrombolytic therapy
Prevent recurrent embolism
Maintain collateral flow
Determine location and mechanism of stroke
Prevent stroke complications
Take steps for secondary prevention
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Evaluation of StrokeEvaluation of Stroke
History and Physical
Diagnostic tests
Brain parenchyma
Vascular system
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15
Brain Attack!Brain Attack!Brain Attack!Brain Attack!
Stroke is a “Brain Attack.”
Stroke happens in the brain not the heart
Stroke is an emergency. Call 911 for emergency treatment.
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Definition of StrokeDefinition of StrokeDefinition of StrokeDefinition of Stroke Sudden brain damage Lack of blood flow to the brain caused by
a clot or rupture of a blood vessel
Ischemic = Clot (makes up approximately
87% of all strokes)
Hemorrhagic = Bleed- Bleeding around brain
- Bleeding into brain
Embolic Thrombotic
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Ischemic vs. Hemorrhagic CVA Ischemic vs. Hemorrhagic CVA Ischemic Stroke
Stepwise deterioration or progressive worsening
Waxing and waning of findings
Focal neurologic signs in the pattern of a single blood vessel
Hemorrhagic CVA Early and prolonged
reduction of consciousness
Prominent headache, nausea, and vomiting
Retinal hemorrhages
Nuchal rigidity
Focal signs may not fit pattern of a single blood vessel
American Heart Association. Heart Disease and Stroke Statistics—2003 Update.
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TIATIATIATIA Transient ischemic attack (TIA) is a warning
sign of a future stroke – up to 40% of TIA patients will have a future stroke
Symptoms of TIAs are the same as stroke TIA symptoms can resolve within minutes or
hours It is important to seek immediate medical
attention if you suspect that you are having or have had a TIA
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Blood TestsBlood Tests rt-PA Candidates
CBC, blood glucose, chemistry, PT, INR, and PTT
Cardiac Enzymes
Homocystein
Fasting Lipid Profile
HgbA1c
Sickle cell disease
Hypercoagulation work-up
Sedimentation rate
ANA
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MRI
CT
Images courtesy of Regional Neurosciences Unit, Newcastle General Hospital, Newcastle, UK.
Evaluation of Brain Parenchyma Evaluation of Brain Parenchyma
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Vascular TestsVascular Tests
Noninvasive
CT R/O bleed R/O other conditions Identify early changes that would
indicate poor rt-PA outcome
CTA To identify clots that could be treated
with IA rt-PA
MRI Confirms area of infarct with-in a few
hours of the infarct
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Vascular TestsVascular TestsNon Invasive
Carotid Dopplers More specific as to degree of carotid stenosis
MRA Defines the degree of stenosis and areas of
occlusion with the brain and neck
Invasive
Conventional cerebral angiography
Risks (should be < 1% risk of stroke or death)
Measurement of lesions
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Evaluation of the Vascular System
Evaluation of the Vascular System
Reprinted with permission from Albers GW, et al. Chest. 2001;119:300S-320S.
Penetrating arterydisease
Flow-reducingcarotid stenosis
Atrial fibrillation
Valve disease
Left ventricularthrombi
Cardiogenicemboli
Aortic archplaque
Carotid plaque witharteriogenic emboli
Intracranialatherosclerosis
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Heart TestsHeart Tests
12-Lead ECG
Telemetry
Echocardiography
TTE
TEE
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Aortic ArchAortic Arch
Transesophageal echocardiography
From: Siddiqui MA, Holmberg MJ, Khan IA. High-grade atherosclerosis of the aorta. Tex Heart Inst J 2002;29:60-2. Accessed at: texasheartinstitute.org/siddi291.html. Copyright © 2002 Texas Heart Institute.
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TREATMENTTREATMENT Thrombolytic therapy ACTIVASE, tPA,
Alteplase
Aspirin
Blood pressure management
Secondary prevention
ASA, antiplatelets
Anticoagulation
Prevention of complications
Rehabilitation
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Thrombolytic Therapy Time Is Brain:
Thrombolytic Therapy Time Is Brain:
IV rt-PA approved in 1996
Must be given at a designated Stroke Center
Must follow guidelines for administration
Use of approved protocols, care maps, standard orders
IA rt-PA under investigation
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Acute Stroke TreatmentsAcute Stroke TreatmentsAcute Stroke TreatmentsAcute Stroke Treatments
Ischemic stroke (Brain Clot)Clot busting medication: t-PA (Tissue Plasminogen Activator)
Clot-removing devices: Merci Retriever, Penumbra
Hemorrhagic Stroke (Brain Bleed)ClippingCoiling
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Current rt-PA Treatment
RecommendationsCurrent rt-PA Treatment
Recommendations Reduce risk of ICH by closely following rt-PA protocol
Time greater than 3 hours – greater than 6 hrs for IA rt-PA
Poor blood pressure control
Wrong dose
Elevated blood sugar
NIHSS Stroke Scale score > 20
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rt-PA Inclusion/Exclusion Criteria rt-PA Inclusion/Exclusion Criteria
Age 18 years or older
Symptoms Onset IV rt-PA – 3 hours or less IA rt-PA – 6 hours or less consider for rt-PA
Head CT – Rule Out Bleed
Any concomitant diseases leading to bleeding? Recent MI, Stroke Recent trauma, major surgery Recent Bleeding
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Exclusion Criteria – rt-PA
Exclusion Criteria – rt-PA
Medications that might increase bleeding? Anticoagulants
Exam findings – high risk of bleeding Systolic BP > 185 Diastolic BP > 110
Lab findings – high risk of bleeding Prolonged INR, PTT Thrombocytopenia
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Exclusion Criteria – rt-PAExclusion Criteria – rt-PA Findings on neurological examination
Very mild Stroke ( NIHSS score < 2-3 ) Very Severe Stroke (NIHSS score > 20)
CT findings Hemorrhage Large Infarction Stroke Looks older than 3 hrs
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Current Usage rt-PA Current Usage rt-PA
Under Usage of rt-PA at Stroke Centers: 1% to 3% Under Usage of rt-PA at Stroke Centers: 1% to 3%
Estimate is that 10% of eligible patients should Estimate is that 10% of eligible patients should receive rt-PA receive rt-PA
The most frequent reason rt-PA is not given is The most frequent reason rt-PA is not given is the patient presents outside the 3 hr. windowthe patient presents outside the 3 hr. window
Patient and Community Education CriticalPatient and Community Education Critical
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Blood Pressure in Ischemic Stroke
Blood Pressure in Ischemic Stroke
Acute elevations of BP are common in stroke
Often declines spontaneously in first 24 - 48 hours
Seen in 85% of patients
Cerebral autoregulation is defective in most patients
Acutely lowering BP can expand area of ischemia
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BP Recommendations for Ischemic Stroke Patients Eligible for ThrombolysisBP Recommendations for Ischemic
Stroke Patients Eligible for Thrombolysis Before rt-PA treatment
Systolic > 185 or diastolic > 110 Labetalol
During and after rt-PA treatment Monitor BP per protocol Diastolic > 140
Nitroprusside Systolic > 230 or diastolic 121 - 140
Labetalol or nicardipine Systolic 180 - 230 or diastolic 105 - 120
Labetalol
Aim for 10%-15% reduction in BP
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BP Recommendations for Ischemic Stroke Patients Not Eligible for
Thrombolysis
BP Recommendations for Ischemic Stroke Patients Not Eligible for
Thrombolysis Systolic < 220 or diastolic < 120
Observe unless other end-organ involvement
Systolic > 220 or diastolic 121 - 140
Labetalol 10-20 mg IV over 1 - 2 min (may repeat or double every 10 min)
Nicardipine
Diastolic >140
Nitroprusside
Aim for 10%-15% reduction in BP
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rt-PA rt-PA Administer within 60 minutes of ED arrival and
within 3 hour onset window
Total IV dose
0.9 mg/Kg X _____(pt wt in Kg) = _____ mg
Maximum total IV dose = 90 mg over 1 hour
Bolus 10% total IV dose over 1 minute
Then give 90% total IV dose over remaining 60 minutes
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TREATMENT /PREVENTION OF COMPLICATIONS
TREATMENT /PREVENTION OF COMPLICATIONS
Blood Sugar Control
Positioning Depends on clinical
situation 30% elevation helps
to prevent aspiration Keeping the patient
flat increases cerebral perfusion but time limited
Bedrest with patients who are susceptible to orthostatic changes
Prevention DVT prophylaxis Aspiration Early Mobilization
Early Mobilization
Depression
Bowel and Bladder Protocol
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New TreatmentsNew Treatments Combined IV and IA Thrombolytics
Clot Retrieval Devices
Neuro-protective Agents
Hypothermia
Hyperbaric Oxygen
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Surgical OptionsSurgical Options
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Decompressive CraniectomyDecompressive Craniectomy Used as a life saving measure for large
hemispheric infarctions
Brain is allowed to swell to decrease ICP and increase perfusion pressure
Portions of the infarcted tissue are resected
Mortality is decreased from 80% to 35%
Outcome is improved
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Acute Therapy: ConclusionsAcute Therapy: Conclusions Acute stroke therapy requires a coordinated
and focused approach
IV rt-PA within 3 hours is a safe and effective if protocols are followed
Workup should determine the cause and mechanism of the stroke
Steps to prevent stroke complications can improve outcomes
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Stroke RecoveryStroke RecoveryStroke RecoveryStroke Recovery
10% of stroke survivors recover almost completely
25% recover with minor impairments
40% experience moderate to severe impairments requiring special care
10% require care within either a skilled-care or other long-term care facility
15% die shortly after the stroke
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Types of Stroke RehabilitationTypes of Stroke RehabilitationTypes of Stroke RehabilitationTypes of Stroke Rehabilitation
Physical Therapy (PT) Walking, range of movement
Occupational Therapy (OT) Taking care of one’s self
Speech Language Therapy Communication skills, swallowing,
cognition
Recreational Therapy Cooking, gardening
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Types of Recovery ServicesTypes of Recovery ServicesTypes of Recovery ServicesTypes of Recovery Services
Rehabilitation unit in the hospital
In-patient rehabilitation facility
Home-bound therapy
Home with outpatient therapy
Long-term care facility
Community-based programs
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Secondary Prevention of Stroke and Other Vascular Events
Secondary Prevention of Stroke and Other Vascular Events
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Secondary PreventionSecondary Prevention Educate the public
One or two education sessions per month
Health fairs BP screening
Cholesterol/triglyceride levels
Serum glucose levels
Presence of A-fib
Lifestyle evaluation
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Blood Pressure Control Is Inadequate in the US
Blood Pressure Control Is Inadequate in the US
Arch Intern Med. 1997;157:2413-2446. JNC-IV. Trilling JS, Froom J. Arch Fam Med. 2000;9:794-801.
Millions of People
13
13.51623
UnawareUntreatedInadequately treated140/90 mm Hg
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Secondary Prevention of Stroke: Percentage Prevented per Year
Secondary Prevention of Stroke: Percentage Prevented per Year
Straus SE, et al. JAMA. 2002;288:1388-1395.
0 2 4 6 8 10 12 14 16 18
% of strokes prevented/yr
AntihypertensivesClopidogrel vs.
ASAWarfarin
Statins
Smoking Cessation
Aspirin
Carotid Endarterectomy
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Modifiable Risk Factors and
Preventable Strokes
Modifiable Risk Factors and
Preventable Strokes
Adapted with permission from Gorelick PB. Stroke. 1994;25:220-224.
*Based on 731,000 strokes.
Risk Factor Projected strokes prevented*
Hypertension 360,000
Smoking 90,000
Atrial Fibrillation 69,000
Heavy Alcohol Consumption
34,000
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AANN Clinical Practice Guideline Series; Guide to the Care of the Hospitalized Patient with Ischemic Stroke 2nd edition
National Stroke Association; National stroke association.org
Guideline for Healthcare Professionals From the American Heart Association/American :Guidelines for the Early Management of Patients With Acute Ischemic Stroke: American Heart/Stroke Association
Biblography/ References
Biblography/ References