DURING A STROKE…

YOU LOSE TWO MILLION BRAIN CELLS PER MINUTE!

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Stroke… Are You Ready?2013

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Saint Luke’s Neuroscience Institute

StrokeBrain Tumor

EpilepsyMinimally Invasive Spine

Movement DisorderRehabilitation Brain Fitness

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Regional Networking

Treats > 1000 ischemic and hemorrhagic strokes

annually

Come by helicopter or ambulance from more than

80 regional hospitals

Acute Treatment Rate Over 30%

SLNI Acute Stroke Intervention2002 – 2012 (preliminary-rev. 1/22/13)

8.9%5.9%

8.2% 7.4%9.4% 8.9% 9.8%

15.9%18.6% 18.9%

16.5%

3.8%

1.8%

2.9%1.6%

1.4% 1.5%2.6%

2.5%

2.0% 1.5%

0.6%9.5%

4.7%

5.1%

3.6%1.8% 2.7%

5.3%

2.8%

3.6%1.6%

0.4%

1.2%

2.3%

1.8%

1.3%3.4% 2.0%

3.2%

3.0%

4.7%4.7%

5.0%

1.8%

9.6%

10.1%

9.6% 7.0%6.0%

8.5%5.6%

7.3%7.2%

2.9%

0.01700000000000010.0176991150442478

0.019

0.0150.023598820058997

0.028

A/S+ A/AS ret + ret ia iv-ia iv

25% 24% 28% 23% 29%23% 21% 30% 39% 38% 30%

Did you know?Stroke ranks 4th in cause of death in the U.S.

Leading cause of serious, long-term disability

$72 billion spent on stroke care per year

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Review of Cerebral Anatomy

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Cerebrum – Frontal • Motor movement• Judgment• Emotion• Speech

– Expressive– Parietal

• Sensory• Speech

– Receptive – Temporal - hearing– Occipital – vision

Speech Centers-Left Hemishpere

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Broca’s Area

• Expressive Aphasia

Wernicke’s Area

• Receptive Aphasia

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Review of Cerebral Anatomy Cerebellum - maintain balance and

further control of movement and coordination.

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Review of Cerebral Anatomy• Brain Stem - automatic

functions, such as control of respiration, heart rate, and blood pressure, wake-fullness, arousal and attention.

LOC – most sensitive indicator of cortical function

Homunculus

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Homunculus

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Cerebral Blood Supply

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Anterior (Carotids)Posterior (Vertebral)

Cerebral Anatomy

• Vascular circulation: Anterior and Posterior • Anterior circulation– Origin: carotid system– supplies 80% brain- optic nerve, retina, frontoparietal and

anterotemporal lobes of brain

• Posterior circulation:– Origin: vertebral arteries– supplies 20% of brain - brainstem, cerebellum, thalamus,

auditory centers and visual cortex

Carotid System

Anterior Cerebral Artery

• It supplies the frontal lobes, the parts of the brain that control logical thought, personality, and voluntary movement, especially the legs.

ACA Stroke

• >Leg weakness & numbness• Confusion

– Slow responses– Cognitive changes

Anterior Cerebral Artery Stroke

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Anterior Cerebral Artery Large Vessel

Middle Cerebral Artery

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• It supplies a portion of the frontal lobe and the lateral surface of the temporal and parietal lobes, including the primary motor and sensory areas of face, upper extremities and speech area. Most often occluded in stroke.

MCA Stroke Symptoms

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• >Arm and face weakness

• Aphasia– Left dominant • Broca – difficulty

speaking• Wernicke – difficult

understanding– Right dominant• Neglect

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Middle Cerebral Artery Stroke

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Middle Cerebral Artery – Large Vessel

• Vertebrals – originate from subclavian – ascend up spinal process and form the basilar artery

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Vertebrobasilar System

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Posterior Circulation

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• It supplies the temporal and occipital lobes of the left cerebral hemisphere and the right hemisphere.

Posterior Cerebral Artery?

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• Contralateral homonymous hemianopsia

• Both-sided involvement can leads to cortical blindness

Posterior Cerebral Artery

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Posterior Circulation

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Brain Stem

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Circle of Willis

• Sits at the base of the brain

• Joins the anterior and posterior circulation

• Most common site for congenital aneurysm

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What is a Stroke?

…a plumbing problem

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Three Stroke Types

IschemicStroke

Clot occludingartery

Intracerebral Hemorrhage

Bleedinginto brain

Subarachnoid Hemorrhage

Bleeding around brain

Focal Brain Dysfunction

Diffuse Brain Dysfunction

Brainstem Typical Signs: Cranial Nerve and Other Deficits

Oropharyngeal Weakness:

Dysarthria (speaking), Dysphagia (swallowing)

Eye Movement Abnormalities:

Diplopia

Dysconjugate Gaze

Gaze Palsy (horizontal gaze

deficit or gaze preference)

Decreased LOC

Nausea, Vomiting

Hiccups, Abnormal Respirations

Vertigo, Tinnitus

Brainstem Typical Signs: Bilateral Abnormalities

Quadriparesis

Sensory Loss

in All 4 Limbs

“Locked In

Syndrome”

Cranial Nerve

Signs

Crossed Signs (1 side of face and contralateral body)Hemiparesis

Hemisensory

Loss

Cerebellum Typical Signs: Lack of Coordination

Ipsilateral (same side) Limb Ataxia (dyscoordination)

Truncal or GaitAtaxia (imbalance)Tremors, or Limb

Ataxia, result from lack of coordination of opposing muscle groups (flexors vs. extensors), causing the muscle groups to fight each other

Left (Dominant) Hemisphere Typical Signs: Right Side Weakness and Aphasia

Aphasia

Left Gaze Preference

Right Hemiparesis

Right Hemisensory Loss

Right Visual Field Deficit

Hemiparesis: weakness or partial

paralysis

Hemiplegia: paralysis

Due to pathology – if left hemisphere stroke (right muscles become paralyzed)– so only muscles working are the left.

Right (Nondominant) Hemisphere Typical Signs: Left Side Weakness

Right Gaze Preference

Left Hemiparesis

Left Hemisensory

Loss

Left Hemi-inattention

(Neglect)Left Visual

Field Deficit

Due to pathology – if right hemisphere stroke (left muscles become paralyzed)– so only muscles working are the left.

Stroke Severity Scoring

• Stroke Severity required on all stroke within one hour of admission.

1.NIH – on ALL strokes2.ICH Score – Intracerebral Hemorrhage3.Hunt and Hess – Non traumatic SAH

(aneurysm)

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Face

Arm S T

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F

A Speech T

You can’t teach an old dog new tricks

AphasiaDysarthria

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F

A S Time

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Last time known wellRouting planLocal-ready?

Bypass or not?This is CRUCIAL because time is the major determinant in what interventions may be effective—Time matters!“Time of onset” is often difficult to determine, so we default to the level of “time last known well”…Most of the TIME.

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Last time known wellRouting planLocal-ready?

Bypass or not?TCD—Local or state?

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Last time known wellRouting planLocal-ready?

Bypass or not?

Is your local facility stroke ready?

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Last time known wellRouting planLocal-ready?

Bypass or not?

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Door to Neurological Assessment….10 min

Door to CT….25 min

Door to CT/Lab interpretation….45 min

Door to Drug….60 min

The Golden Hour of Stroke Treatment

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Saint Luke’s Stroke Treatment Options

IV tPA…….up to 3-4.5 hours

Intra-arterial tPA.......up to 6 hours

Mechanical clot retrieval.......up to 8 hours

Wake-up stroke treatment options available

Clipping or Coiling of ruptured aneurysms within 24 hours

Clinical Trials

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Case Study #1

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82 femaleLeft-sided weaknessSlurred speechVision lossGaze deviationNeglect

PMH: atrial fibrillation, hyperlipidemia and hypertension

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NIHSS 9

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Perfusion Cerebral Blood Volume Mean Transit Time

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Saint Luke’s Stroke Treatment Options

IV tPA…….up to 3-4.5 hours

Intra-arterial tPA.......up to 6 hours

Mechanical Clot retrieval.......up to 8 hours

Wake-up stroke treatment options available

Clipping or Coiling of ruptured aneurysms within 24 hours

Clinical Trials

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MRI Perfusion

NIHSS 3 at 24 hours post-interventionDischarged with home health

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“ We wanted my mom to go to her community hospital…….the EMS crew said we needed to go to Saint Luke’s for stroke care and we are so thankful we listened”

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Case Study #2

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86 femaleSudden worst headache of her lifeDecreased LOC Visual disturbanceRight-sided weaknessAphasia

PMH: heart and lung disease and recently quit smoking

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Saint Luke’s Stroke Treatment Options

IV tPA…….up to 3-4.5 hours

Intra-arterial tPA.......up to 6 hours

Mechanical Clot retrieval.......up to 8 hours

Wake-up stroke treatment options available

Clipping or Coiling of ruptured aneurysms within 24 hours

Clinical Trials

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Repeat CT—5 days later

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DispositionIn-patient Rehab

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Case Study #3

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74 y/o male EMS called at 0630 when wife found him Right hemiplegiaAphasiaLast known w/o stroke symptoms: 8pm the night before

PMH: renal disease, diabetes, htn, pacemaker & PVD

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NIHSS 23

Cerebral Angiogram: small clot in left MCA

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Cerebral Arteriogram

Small clot in the left MCA

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Saint Luke’s Stroke Treatment Options

IV tPA…….up to 3-4.5 hours

Intra-arterial tPA.......up to 6 hours

Mechanical Clot retrieval.......up to 8 hours

Wake-up stroke treatment options available

Clipping or Coiling of ruptured aneurysms within 24 hours

Clinical Trials

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Cerebral Arteriogram

Successful intra-arterial thrombolysis of left MCA thrombus with restoration of

flow

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Pt. experienced vtach during procedure and converted without meds

NIHSS 9 at 24 hours post-procedure

He remained in the ICU longer than normal due to complicated medical history, but recovered well from his

stroke

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Case Study #479 y/o right-handed female

Sudden onset of right-sided weakness at 1030

EMS transported to local ED

Hx: Diabetes, CAD, Dyslipidemia, Stroke

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No acute CT findings

No exclusion criteria identified

Phone consult with Neurology at SLH

Collaborative decision made to start IV tPA and immediately transfer for possible further intervention

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Saint Luke’s Stroke Treatment Options

IV tPA…….up to 3-4.5 hours

Intra-arterial tPA.......up to 6 hours

Mechanical Clot retrieval.......up to 8 hours

Wake-up stroke treatment options available

Clipping or Coiling of ruptured aneurysms within 24 hours

Clinical Trials

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NIHSS 3Improved following tPA CT Perfusion

No large vessel perfusion deficit

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CT HeadNo acute findings

Complete Resolution of Neurological Deficits

Discharged Home

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Case Study #552-year-old female

Sudden onset of difficulty speaking

Resolved upon EMS arrival

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10 hours later...Incomprehensible speech

Right sided paralysis

Left gaze deviation

What does a mulligan have in common with a TIA?

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TIA Statistics…

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10% of all strokes are preceded by TIAs

1/3 of all persons who experience TIAs…will go on to have an actual stroke• 5% of those strokes will occur within ONE month• 50% within 48hours

Videos

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Mild StrokeNIH Stroke Scale: stroke severity scale (0-42)

<5 Mild impairment 10-20 Moderate impairment >20 Severe impairment

Predicted need for long-term nursing care <6 Most will return home 6-13 Most will need short-term hospital care >13 Most will need long-term nursing care

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Stroke Mimics

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Field Decisions

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Stroke Management Transport Protocols

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• Post IV tPA Treatment & Management• Document neuro assessment & blood pressure Q15min

• If change in neuro: STOP tPA, assess ABC’s & vitals & glucose

• Maintain BP<180/105 after administration and during transport

• Hypertension: Labetalol 10mg IV over 2min. Recheck in 5min; may repeat x1 (do not use if heart rate <60)

• Stop BP infusion if SBP<140 or DBP<80

• Hypotension: STOP tPA, HOB flat, turn off drips, 500ml fluid bolus(NS), reassess

• Start NS at 80ml/hr after infusion complete to clear line and continue if no hx of CHF

The Challenge Increase Access to IVtPA Safely

•Stroke treatment with IVtPA is time dependent•Patients will most likely present to the closest hospital•Earlier treatment is associated with better outcomes

•The presenting hospital may be able to administer IVtPA but cannot provide intensive monitoring during first 24 hours•The patient is transferred to a more comprehensive center

•Transfer protocols with IVtPA running are not standardized•Is it safe to “ship” the patient immediately after starting tPA?

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Is Immediate Transport Safe?• Retrospective review of consecutive “drip and

ship” cases 2008-2010.• Analysis– SICH or BP>180/105 on arrival– Inaccurate stroke diagnosis– Need for intra-arterial (IA) treatment– Mortality rate– Clinical outcome (mRS at 90 days)

• Location and Size of referring hospital

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Results

1626 ischemic strokes 717 (44%) were transferred

145 (20%) of transferred cases

were “drip and ship”

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63 Referring Hospitals

90% >10 miles63% >50 miles25% > 100 miles

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29 Critical Access Hospitals of <25 beds

Results

Mean Age - 67.5 years

Mean admission NIHSS score - 10.4

Mean discharge NIHSS score - 3

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Blood Pressure on Arrival

1 SICH

•BP=183/77•MortalityNo

hemorrhage

•BP=232/84•Mortality10

/14

•mRS 0-2 at 90 days

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9.6% had BP >180/105

Hemorrhage on Arrival

4 •4 (2.7%) cases had SICH on arrival•3 of these had BP <180/105

2 •2 mortalities related to SICH•1 mortality had BP>180/105

2 •Admit NIHSS 25; discharge NIHSS 4•Admit NIHSS 18; discharge NIHSS 10

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Outcomes

mRS 0-2 at 90 days = 72/114 (63%)Note: mRS scores not available for 2008

Mortality = 20/145 (13.7%) IA therapy = 35/145 (24%)Inaccurate diagnosis at sending facility = 6/145 (4.1%) ; all had excellent clinical outcomes.

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Gtt & Ship Data

• Immediate transport of patients with IV tPA infusing is safe with a low incidence of SICH en route

• >90% had BP <180/105 on arrival• The 63% good outcomes may, in part, relate to early

treatment with IV tPA in referring hospitals• Hospitals of every size and location can safely treat

stroke victims with IV tPA if they have access to consultation and transfer agreements with experienced stroke centers

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Non-tPA treated patientsTarget BP—220/120

Follow blood pressure management protocol

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Hemorrhagic StrokeTarget BP < =160/90

Follow BP management protocol

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Follow-up

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MERCI Retriever “The Corkscrew”

Outcomes for patients who received treatment with the Solitaire system during clinical trial:

• Brain artery opened 83% of the time in comparison to 48% with the Merci retriever catheter• Good clinical outcomes 58% of the time vs. 33% with Merci• 55% reduction in patient mortality at 3 months using Solitaire vs. Merci

Solitaire Device

Types of Clots Retrieved

Basilar Clot Basilar artery blocked

Clots

Discussion

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