BRAIN ATTACK 

 

UNDERSTANDING AND MANAGING ACUTE STROKE

Carolyn Walker RN, BN.

January 2011QuickTime™ and a

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Brain Attack: Brain Attack: Understanding Understanding and Managing Acute Strokeand Managing Acute Stroke

Learning ObjectivesLearning Objectives::

Upon completion of this session, participants will be able Upon completion of this session, participants will be able to:to:

Describe the 2 major types of strokeDescribe the 2 major types of stroke Identify the location of stroke given stroke symptomsIdentify the location of stroke given stroke symptoms Describe the management of hypertension in acute Describe the management of hypertension in acute

strokestroke Explain the appropriate management of acute ischemic Explain the appropriate management of acute ischemic

strokestroke

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Epidemiology of Stroke: Epidemiology of Stroke: The Canadian PerspectiveThe Canadian Perspective

50,000 new stroke patients/year in Canada50,000 new stroke patients/year in Canada††

5,500 Albertans suffer a stroke each year5,500 Albertans suffer a stroke each year Every 10 minutes someone in Canada suffers a “brain attack”Every 10 minutes someone in Canada suffers a “brain attack”

33rdrd leading cause of death in Canada leading cause of death in Canada The leading cause of adult disabilityThe leading cause of adult disability 200,000–300,000 stroke survivors200,000–300,000 stroke survivors††

Cost to society: $300-400 million/yr AlbertaCost to society: $300-400 million/yr Alberta

28% of stroke patients are under age 65*28% of stroke patients are under age 65*

†Statistics Canada

What is a stroke?What is a stroke?BLOCKAGEBLOCKAGE BREAKAGE BREAKAGE

blood vessel occlusion blood vessel occlusion or or blood vessel rupture blood vessel rupture (clot / atherosclerosis)(clot / atherosclerosis)

sudden interruption in cerebral blood flow sudden interruption in cerebral blood flow

brain injury to affected areabrain injury to affected area

brain death of affected areabrain death of affected area

Stroke: Brain AttackStroke: Brain Attack

Stroke is a Stroke is a

““brain attack”brain attack”

Stroke is an Stroke is an EMERGENCY!EMERGENCY!

Frequency of Stroke by TypeFrequency of Stroke by Type

IschemicIschemic (85%) (85%) Thrombotic (54%), Embolic (31%)Thrombotic (54%), Embolic (31%)

Ischemic Stroke – 65%Ischemic Stroke – 65% TIA – 20%TIA – 20%

symptoms resolvesymptoms resolve no brain cell deathno brain cell death 20-40% of strokes are proceeded 20-40% of strokes are proceeded

by TIAby TIA

HemorrhagicHemorrhagic (15%) (15%) Intracerebral – 10%Intracerebral – 10% Subarachnoid – 5%Subarachnoid – 5%

Blockage

Breakage

The BrainThe Brain

CerebrumCerebrum DiencephalonDiencephalon CerebellumCerebellum BrainstemBrainstem

CerebrumCerebrum

Center for highest functionCenter for highest function Governs thought, memory, reasoning, Governs thought, memory, reasoning,

sensation and voluntary movementsensation and voluntary movement Divided into two hemispheresDivided into two hemispheres Left Hemisphere Left Hemisphere

dominant in 95% of peopledominant in 95% of people Right HemisphereRight Hemisphere

Functions of Cerebral HemispheresFunctions of Cerebral Hemispheres

PHOTO: Courtesy of National Stroke Association

Cerebellum

Motor and Sensory FunctionMotor and Sensory Function

PHOTO: Courtesy of National Stroke Association

CerebrumCerebrum

Basal gangliaBasal ganglia Bands of grey matter deep within the Bands of grey matter deep within the

cerebral hemispherescerebral hemispheres Control automatic associated movementsControl automatic associated movements

i.e. arm swing alternating with leg movementi.e. arm swing alternating with leg movement postureposture

DiencephalonDiencephalon

Includes Includes thalamusthalamus and and hypothalamushypothalamus Extends from cerebrum to midbrainExtends from cerebrum to midbrain Surrounds 3Surrounds 3rdrd ventricle ventricle ThalamusThalamus

Receives sensory inputReceives sensory input Relay station to cerebral cortexRelay station to cerebral cortex

HypothalamusHypothalamus Major control centreMajor control centre Regulation of temp, HRegulation of temp, H22O balance, sleep, behaviorO balance, sleep, behavior Coordinator of autonomic nervous system activityCoordinator of autonomic nervous system activity

CerebellumCerebellum

Located under occipital lobeLocated under occipital lobe Unconscious motor coordination of Unconscious motor coordination of

voluntary movementvoluntary movement i.e. complex coordination of different muscles i.e. complex coordination of different muscles

needed to juggle, swim, etc.needed to juggle, swim, etc. EquilibriumEquilibrium Muscle toneMuscle tone

Brain StemBrain Stem

Central core of brainCentral core of brain Consists mostly of nerve fibersConsists mostly of nerve fibers MidbrainMidbrain

Auditory/visual systemsAuditory/visual systems PonsPons

Respiratory centersRespiratory centers MedullaMedulla

Respiratory and vasomotor controlRespiratory and vasomotor control

Blood Supply to the BrainBlood Supply to the Brain

PHOTO: Courtesy of National Stroke Association

Blood Supply to the BrainBlood Supply to the Brain

Blood Supply to the BrainBlood Supply to the Brain

Carotid Arteries & Branches:Carotid Arteries & Branches:anterior 2/3 cerebral ofanterior 2/3 cerebral ofhemisphereshemispheres

Vertebral Arteries & Branches:Vertebral Arteries & Branches:posterior and medial posterior and medial regions of hemispheresregions of hemispheresbrainstembrainstemdiencephalon diencephalon (thalamus/hypothalamus)(thalamus/hypothalamus)

cerebellumcerebellum Courtesy GenentechCourtesy Genentech

90% of all strokes

10% of all strokes

Hemorrhagic StrokeHemorrhagic Stroke

Intracerebral Hemorrhage Subarachnoid hemorrhage

Intracerebral HemorrhageIntracerebral Hemorrhage Result of ruptured Result of ruptured

Blood vesselBlood vessel Hypertension most Hypertension most

common causecommon cause

Usual Presentation:Usual Presentation: HeadacheHeadache HemiplegiaHemiplegia Decreased levelDecreased level

of consciousnessof consciousness Nausea & VomitingNausea & Vomiting

Subarachnoid HemorrhageSubarachnoid Hemorrhage Blood vessel ruptures & bleeds into Blood vessel ruptures & bleeds into

subarachnoid space subarachnoid space (Aneurysms/arteriovenous malformations )(Aneurysms/arteriovenous malformations )

““Worst headache of one’s life”Worst headache of one’s life” Nausea & vomitingNausea & vomiting Neck stiffness Neck stiffness Neurologic signs don’t fit Neurologic signs don’t fit

pattern of a single blood vesselpattern of a single blood vessel Varying level of consciousnessVarying level of consciousness

Management of SAH and ICH:Management of SAH and ICH:The First Few HoursThe First Few Hours

Correct airway, breathing or Correct airway, breathing or circulationcirculation

Treat severe elevation of BPTreat severe elevation of BP Obtain neurosurgical consultObtain neurosurgical consult Treat elevated intracranial pressureTreat elevated intracranial pressure Admin anticonvulsant therapy if Admin anticonvulsant therapy if

seizuresseizures

Recommendations:Recommendations:

Maintain SBP < 180 mmHg and DBP < 100 mmHg Maintain SBP < 180 mmHg and DBP < 100 mmHg

MAP < 130 mmHg if history of hypertensionMAP < 130 mmHg if history of hypertension

DO NOT REDUCE BP BY MORE THAN 20%DO NOT REDUCE BP BY MORE THAN 20%

CONTACT STROKE SPECIALIST AT COMPREHENSIVE CONTACT STROKE SPECIALIST AT COMPREHENSIVE STROKE CENTER!STROKE CENTER!

Intracerebral Hemorrhage: Intracerebral Hemorrhage: Hypertension ManagementHypertension Management

Ischemic Stroke - Ischemic Stroke - The ProblemThe Problem

Etiology of Ischemic StrokeEtiology of Ischemic Stroke

Graphics courtesy Boehringer Ingelheim

Classifications of Ischemic Classifications of Ischemic Stroke Stroke

Small vessel diseaseSmall vessel disease Lacunar infarctionLacunar infarction

Large vessel diseaseLarge vessel disease Artery to artery emboli (large artery atherosclerosis)Artery to artery emboli (large artery atherosclerosis)

CardioembolicCardioembolic Cryptogenic (Don’t know the Cause)Cryptogenic (Don’t know the Cause) Other (Cocaine, coagulopathies)Other (Cocaine, coagulopathies)

Progression of Ischemic Progression of Ischemic StrokeStroke

Graphics courtesy Boehringer Ingelheim

TIME TIME IS BRAIN!IS BRAIN!

In a typical large vessel acute In a typical large vessel acute ischemic stroke…ischemic stroke…

- 1.9 million neurons - 1.9 million neurons - 14 billion synapses - 14 billion synapses

- 12 km of myelinated - 12 km of myelinated fibers fibers

are destroyed each minute …are destroyed each minute …

(JL Saver, 2006)(JL Saver, 2006)

Symptoms of “Brain Attack”Symptoms of “Brain Attack”

Speech

Strength

Sight

ACUTE STROKE OUTCOMES CAN ACUTE STROKE OUTCOMES CAN BE IMPROVED IF WE PROVIDE ABE IMPROVED IF WE PROVIDE A

RAPID COORDINATED RAPID COORDINATED RESPONSE!RESPONSE!

Approaches to Acute TherapyApproaches to Acute Therapy

NeuroprotectionNeuroprotection Studies*Studies*

ReperfusionReperfusion

REPERFUSION - Thrombolytic AgentsREPERFUSION - Thrombolytic Agents

Intravenous rt-PAIntravenous rt-PA Strict protocols for use with ischemic Strict protocols for use with ischemic

strokestroke

Improves outcomes compared to the risk Improves outcomes compared to the risk of serious bleedingof serious bleeding

Canadian Stroke Strategy:Canadian Stroke Strategy:Best Practice Recommendations 2010Best Practice Recommendations 2010

All patients with disabling acute ischemic All patients with disabling acute ischemic stroke who can be stroke who can be treated within 4.5 hours treated within 4.5 hours after symptom onset should be evaluated after symptom onset should be evaluated without delaywithout delay to determine their eligibility to determine their eligibility for treatment with t-PA.for treatment with t-PA.

Diminishing Returns over TimeFavorable Outcome (mRS 0-1, BI 95-100, NIHH 0-1) at Day 90 Adjusted odds ratio with 95% confidence interval by stroke onset to treatment time (OTT) ITT population (N=2776)

Pooled Analysis NINDS tPA, ATLANTIS, ECASS-I, ECASS-IICourtesy Brott T et al

REPERFUSIONREPERFUSION

Intra-arterial lytic Intra-arterial lytic

ultrasonic clot-bustingultrasonic clot-busting

REPERFUSION: Devices - Clot REPERFUSION: Devices - Clot RetrievalRetrieval

Mechanical Thrombectomy DevicesMechanical Thrombectomy Devices- MERCI study: MERCI deviceMERCI study: MERCI device MMechanical echanical EEmbolus mbolus RRemoval in emoval in CCerebral erebral

IIschemia schemia

- Penumbra devicePenumbra device

Canadian Stroke Strategy:Canadian Stroke Strategy:Best Practice Recommendations 2010Best Practice Recommendations 2010

There remain situations where there are sparse or There remain situations where there are sparse or little clinical trial data to support the use of little clinical trial data to support the use of thrombolytic therapy:thrombolytic therapy: Paediatric strokePaediatric stroke Over 80 years with diabetesOver 80 years with diabetes Present within time window but do not meet current Present within time window but do not meet current

criteria for treatment with IV t-PAcriteria for treatment with IV t-PA Intra-arterial thrombolysisIntra-arterial thrombolysis

Treat based on clinical decision of physician and Treat based on clinical decision of physician and familyfamily

EMS Protocol- Arrival at sceneEMS Protocol- Arrival at scenePRIORITY IS LOAD AND GOPRIORITY IS LOAD AND GO

ABC’s firstABC’s first

Determine Determine time last known to be normaltime last known to be normal

Acute Stroke ScreenAcute Stroke Screen

Perform directed neurological assessmentPerform directed neurological assessment

Blockage or Breakage?Blockage or Breakage?

Onset TimeOnset Time

Onset Time = Time when patient was last Onset Time = Time when patient was last seen wellseen well

Requires detective skillsRequires detective skills

Pre-Hospital Care:Pre-Hospital Care:Direct transport to Primary Stroke Centre Direct transport to Primary Stroke Centre

(PSC)(PSC) A standardized acute stroke diagnostic screening tool A standardized acute stroke diagnostic screening tool

should be used by paramedicsshould be used by paramedics

Pts with symptoms of stroke should be transported Pts with symptoms of stroke should be transported without delay to the closest institution that provides without delay to the closest institution that provides emergency stroke careemergency stroke care

Direct Direct transport protocols transport protocols must be in placemust be in place

Paramedics must notify the receiving facilityParamedics must notify the receiving facility

Transfer care to receiving facility Transfer care to receiving facility without delay without delay (scene time < 10 min)(scene time < 10 min)

EMS Stroke Screening FormEMS Stroke Screening Form

0 10 20 30 40 50 60 70 80 90

minutes

8 miles40 miles

vs

CT scanner

Local hospitalNo CT scanner

70 miles

Helical or multislice CT scanner 24h/365d coveragePrimary Stroke Center

170 miles

intraclot lysis

Interventional Facilities- interventional neurorad, neurosurgery

Comprehensive Stroke Center

ICH evacuation

vs

vs

Early ICA revascularization

Alberta Stroke Centre LocationsPrimary Stroke Centre (PSC): 14

• CT scan availability• Door to CT < 20 min. with a pre-alert• Stroke expertise on-site or available by

Telestroke link• r-tPA treatment availability • May not be available 24/7

Comprehensive Stroke Centre (CSC): 3

• CT scan availability• Door to CT < 20 minutes with a pre-alert• Stroke team on-site• Neurological expertise on-site• Neurointerventional expertise on-site• Central hub of stroke Neurologist

expertise in a telestroke network

Initial Management of Stroke:Initial Management of Stroke:A. Immediate General AssessmentA. Immediate General Assessment

Assess A B C’s, vital signs Assess A B C’s, vital signs (BP, HR, Temp***)(BP, HR, Temp***)

Provide oxygen Provide oxygen (O2 sats >95%, (O2 sats >95%, if COPD >90%if COPD >90%)) Start an IV Line (large bore)- Start an IV Line (large bore)- no dextroseno dextrose

12 Lead ECG / cardiac monitoring12 Lead ECG / cardiac monitoring Obtain blood samples Obtain blood samples (CBC, lytes, Cr, gluc, PTT, INR) (CBC, lytes, Cr, gluc, PTT, INR)

Check Blood Sugar Levels***Check Blood Sugar Levels*** Perform general neurological screeningPerform general neurological screening Alert Stroke TeamAlert Stroke Team

Canadian Stroke Strategy:Canadian Stroke Strategy:Best Practice Recommendations Best Practice Recommendations

20102010 Monitoring in the acute phase should includeMonitoring in the acute phase should include

HR and rhythm, BP, temp, O2 sat, hydration, swallowing ability and HR and rhythm, BP, temp, O2 sat, hydration, swallowing ability and presence of seizure activitypresence of seizure activity

Initial blood work should includeInitial blood work should include CBC, lytes, Cr, urea, glucose, INR, PTT, TSH, fasting lipids, CK and CBC, lytes, Cr, urea, glucose, INR, PTT, TSH, fasting lipids, CK and

troponintroponin Neurovascular Imaging – should undergo brain imaging (MRI or Neurovascular Imaging – should undergo brain imaging (MRI or

CT) immediatelyCT) immediately Vascular imaging of the brain and neck arteries ASAPVascular imaging of the brain and neck arteries ASAP

Cardiovascular investigationsCardiovascular investigations After initial ECG-daily ECG’s x 72 hrs After initial ECG-daily ECG’s x 72 hrs May also monitor x 72 hrs to detect afibMay also monitor x 72 hrs to detect afib Echocardiography if suspect embolic strokeEchocardiography if suspect embolic stroke

Canadian Stroke Strategy:Canadian Stroke Strategy:Best Practice Recommendations Best Practice Recommendations

20102010 Acute Aspirin TherapyAcute Aspirin Therapy

All stroke pts not on antiplatelet therapy should be All stroke pts not on antiplatelet therapy should be given at least 160 mg of ASA immediately as a one given at least 160 mg of ASA immediately as a one time loading dose after brain imaging excludes time loading dose after brain imaging excludes hemorrhagehemorrhage

If treated with t_PA- delay ASA until after 24 hour If treated with t_PA- delay ASA until after 24 hour CT excluding hemorrhageCT excluding hemorrhage

If taking ASA may consider plavixIf taking ASA may consider plavix

Hypertension During Acute StrokeHypertension During Acute Stroke

Systolic BP > 160mmHg is seen in over 60% Systolic BP > 160mmHg is seen in over 60% stroke patients stroke patients (Robinson et al, Cerebrovasc Dis., 1997)(Robinson et al, Cerebrovasc Dis., 1997)

Often transient, lasting 24-72 hours and in Often transient, lasting 24-72 hours and in most patients does not require treatment.most patients does not require treatment.

Little evidence and no benefit seen for rapid Little evidence and no benefit seen for rapid lowering of BP in acute stroke without rt-PAlowering of BP in acute stroke without rt-PA

Blood Pressure Management:Blood Pressure Management:

Recommendations:Recommendations: Hold emergency hypertension treatment unless: Hold emergency hypertension treatment unless: SBP > 220mmHg or DBP > 120mmHgSBP > 220mmHg or DBP > 120mmHg

Be aware…aggressive lowering of BP may cause Be aware…aggressive lowering of BP may cause neurological worseningneurological worsening

Avoid Over Treating!Avoid Over Treating!

B. Immediate Neurological B. Immediate Neurological AssessmentAssessment

Review patient history and risk factorsReview patient history and risk factors Establish onset of stroke symptomsEstablish onset of stroke symptoms NPO pending swallow screenNPO pending swallow screen Perform physical examPerform physical exam

Determine LOC (GCS)Determine LOC (GCS) Determine level of severity (NIH stroke scale)Determine level of severity (NIH stroke scale)

Transfer for CT exam: possible t-PATransfer for CT exam: possible t-PA Determine if Determine if HemorrhagicHemorrhagic or or IschemicIschemic

C. Immediate TreatmentC. Immediate Treatment

Determine if Hemorrhagic or Ischemic?Determine if Hemorrhagic or Ischemic? HemorrhagicHemorrhagic

Reverse anticoagulantsReverse anticoagulants Reverse bleeding disorderReverse bleeding disorder Monitor neurological conditionMonitor neurological condition Treat blood pressure as requiredTreat blood pressure as required

IschemicIschemic ThrombolyticsThrombolytics Neuroprotectants?Neuroprotectants?

D. Continued ManagementD. Continued Management

Continue therapies begun in ERContinue therapies begun in ER Implement Stroke Orders Implement Stroke Orders Monitor patient status (vital signs, Monitor patient status (vital signs, temptemp, NIHSS, , NIHSS,

glucoseglucose, fluid balance, nutrition, etc.), fluid balance, nutrition, etc.) Initiate interventions to prevent medical or neurologic Initiate interventions to prevent medical or neurologic

complications complications Treat serious co-morbid diseases or risk factorsTreat serious co-morbid diseases or risk factors Perform evaluations to determine the cause of strokePerform evaluations to determine the cause of stroke

D.D. Continued ManagementContinued Management Integrated Multidisciplinary Stroke CareIntegrated Multidisciplinary Stroke Care

Multidisciplinary

Stroke Unit

Emergency

Department

t-PA / ICU

DirectIn Hospital Rehab

Institutional Care + Rehab

Out patient

Rehab

Home

Emergent Stroke Care and the Emergent Stroke Care and the Chain of SurvivalChain of Survival

Identify symptoms

Calling 911

EMS System

ED Staff / Stroke team

Stroke Unit

Rehab / Prevention

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