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Update on Stroke Management
Live from JJ Baumann MS, RN, CNS
Ischemic StrokeFocus on providing treatment quickly!
Patients get treatment faster if :Stroke severity is highArrive by ambulanceArrival during regular hours
Faster treatment times were associated with:
Reduced in-hospital mortality Reduced symptomatic intracranial hemorrhage Increased independent ambulation at discharge Increased discharge to home
Saver et al. Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA. 2013;309(23):2480-2488
Goal door to needle time < 60 minutes
Raising the bar…Meet goal door to needle time in 80% of cases
Ischemic Stroke Treatment
Alteplase – Extending the Window
ECASS 3 extended the time window for tPA…
3-4.5 hour window
Exclusions:• > 80 years old• Taking oral anticoagulants
regardless of INR• Baseline NIHSS > 25• > 1/3 MCA territory has
injury on CT• History of stroke and
diabetesNot FDA approved!
Alteplase and the New Anticoagulants
Direct factor Xa inhibitors – do not use tPA unless not used for more than 2 days or sensitivity tests (aPTT, INR, platelet count, and ECT or TT) are normal
Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trialRaul G Nogueira, Helmi L Lutsep, Rishi Gupta, Tudor G Jovin, Gregory W Albers, Gary A Walker, David S Liebeskind, Wade S Smith, for theTREVO 2 Trialists Lancet 2012; 380: 1231–40
Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised,parallel-group, non-inferiority trialJeffrey L Saver, Reza Jahan, Elad I Levy, Tudor G Jovin, Blaise Baxter, Raul G Nogueira, Wayne Clark, Ronald Budzik, Osama O Zaidat, for theSWIFT TrialistsLancet 2012; 380: 1241–49
Neuro Intervention?
• SWIFT– Primary efficacy outcome recanalisation without ICH – Solitaire 61% vs. Merci 24%, p<0.0001
• TREVO 2– Primary efficacy outcome TICI score 2-3 – Trevo 86% vs. Merci 60%, p<0.0001
Stent retrievers are preferred over MERCI or Penumbra
Ischemic Stroke Blood Pressure
• Hold BP medications unless SBP > 220 or DBP > 120
• Lower 15% in the first 24 hours
Ischemic Stroke - ALIAS
ALIAS - High-Dose Albumin Therapy for Neuroprotection in Acute Ischemic Stroke (M
Ginsberg, MD)
• Use albumin to reduce brain swelling and improve neurologic outcomes.
• Stopped due to frutility.• No benefit.
Ischemic Stroke Prevention
RE-LY Trial: Dabigatran versus Warfarin in Patients with Atrial Fibrillation
Connolly SJ, Ezekowitz MD, et al. NEJM. 2009;361;1-13.
ROCKET AF:Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation
Patel, MR, et al. N Engl J Med 2011; 365:883-891.
ARISTOTLE Trial:Apixaban non-inferior to warfarin in AF patients.
Granger, CB, et al. N Engl J Med 2011; 365:981-992.
Intracranial Hemorrhage
Prothrombin Complex Concentrate (PCC) is preferred over rFVIIa.
Phase 2 trial Promising results:
ICH volume smaller35% reduction in mortalityLess disabilitySlightly more clotting events (e.g. PE’s ,DVT, MI’s)
Phase 3 trialEffectiveNo change in mortality or morbidity
Intracranial Hemorrhage Treatment
• STICH II – early surgery does not increase the rate of death
or disability at 6 months – small but clinically relevant survival advantage for
patients with spontaneous superficial intracerebral hemorrhage without intraventricular hemorrhage.
Mendelow, et al. Early surgery versus initial conservative treatment inpatients with spontaneous supratentorial lobar intracerebralhaematomas (STICH II): a randomised trialLancet. Volume 382, Issue 9890, 3–9 August 2013, Pages 397–408.
Intracranial Hemorrhage Treatment
Minimally Invasive Surgery plus rt-PA for ICH Evacuation (MISTIE)
Less peri-hematoma edema than control group
Effective and safe clot removal
Mould el al. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke. 2013 Mar ;44(3):627-34.
Intracranial Hemorrhage: Blood Pressure
Need enough pressure for injured area to get blood from other vessels
Too much pressure these vessels will burst or bleed more
Intracranial Hemorrhage: Current BP Guidelines
Class IIa Recommendation “In favor of”• SBP 150 – 220 lower SBP to 140Class IIb Recommendation “Less well established”• SBP > 200 or MAP > 150 give IV infusion• SBP > 180 or MAP > 130 ↑ICP monitor ICP,
give intermittent or continuous IV medication• SBP > 180 or MAP > 130 maintain BP 160/90 or
MAP 110 with intermittent or continuous IV medication
Intracranial Hemorrhage: Blood Pressure Trial
Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) II
• Hypothesis: SBP reduction to ≤140 mm Hg reduces the likelihood of death or disability at 3 months after ICH
• Start IV nicardipine within 3 hours of onset of ICH and continue for 24 hours
Subarachnoid hemorrhage
• Early aneurysm repair preferred• Amicar – Early, short course– Avoid antifibrinolytic therapy > 48 post ictus or > 3
days, concern with side effects – Screen for DVT while on
Vasospasm
• Monitor for delayed cerebral ischemia (DCI) in environment with expertise in SAH
• Give Nimodipine 60mg every 4 hours for 21 days
• Detect DCI with TCD, DSA, CTA, EEG, PbtO2
Move to Comprehensive, Multi-disciplinary and Multi-dimensional Stroke Care
Advance Practice Nursing
NeuroIR, Physiatry, Therapist
EVDs, tx of AVM, aSAH
IV tPANeuro
Critical Care
NIR
NSurg Leadership,Care Level
Access to SHC
Patient Outcomes
8 metrics 26 metrics
Meaningful Use
Education to OSH
Research Education/ info sharing
CSC specific resources
Primary Stroke Care Center
Delivering/ Facilitating
Clinical Care
ProgramManagement
Clinical Information
Management
Supporting Self Management
Performance Improvement/ Measurement
Vascular, Rehab,
Stroke RNs
Critical Care Medicine
RadiologyComprehensive Stroke Center
ABCs of Stroke
• Airway• Breathing• Circulation• Disability / DVT• Education• Fever / Food• Glycemic control• Hypo / Hypertension• Imaging
Airway
• Keep NPO until swallow screen performed
• Good oral care
Breathing
• Lung sounds• Oxygen saturation – Use supplemental
oxygen to keep SaO2 > 92%
• Shortness of breath
Circulation
• At least 2 IV sites• Use isotonic solution, not
dextrose, for maintenance fluid
• Coumadin / warfarin• Pradaxa/ Dabigatran
1. What is the goal INR for each?
2. What if the patient has a feeding tube?
Disability / DVT
• Neuro checks• Early mobilization• OOB• Work with rehab– Frozen shoulder– Sitting at edge of
bed–Verbal cues
• SCDs• lovenox• heparin
Education
• Diagnosis• Interventions• Signs of stroke, calling 911• Risk Factors
Risk Factors • HTN• Smoking• Heart disease• cholesterol• xs EtOH• Sedentary life style• DM• AF• Prior stroke or TIA
• Age• Sex• Race• Hereditary
Fever
• Treat fever aggressively– acetaminophen,
ibuprofen – Surface / intravascular
cooling – avoid shivering
• Prevent infection– Aspiration pneumonia– Urinary tract infection
Food
• Oral intake• Feeding tub or PEG• Constipation• Also consider:– Malnourished on admission?– How long do we take to help feed?– Enough calories?
Glycemic Control
• Blood sugar monitoring• HgA1c• How to control?• Avoid the lows!
Hypertension
JNC 7 report. Journal of the American Medical Association. 2003;289:2560-2572.
What to do…
Need Higher
Low perfusion in brain- tight ICA, MCA
Stroke not completed
***Does the neuro exam decline with decreased BP?
Need Lower
Completed their stroke
At risk of bleeding
***Slow and steady!
Imaging
• CT• MRI• TTE• TEE
Stroke Certification for Nurses
Stroke Certified Registered Nurse (SCRN)
American Board of Neuroscience Nursing (ABNN) exam
Through American Association of Neuroscience Nurses
ANVC Certification Exams (NVRN-BC) & (ANVP-BC)
Neurovascular Registered Nurse - Board CertifiedAdvanced Neurovascular Practitioner - Board Certified
Through the Association of Neurovascular Clinicians (ANVC)
Guidelines• Connolly ES Jr.., Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal
subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012;43:1711–37.
• Jauch EC, Saver JL, Adams HP Jr., Bruno A, Connors JJ, Demaerschalk BM, et al.; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947.
• Morgenstern LB, Hemphill JC 3rd., Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010;41:2108–29
• Summers D, Leonard A, Wentworth D, Saver JL, Simpson J, Spilker JA, Hock N, Miller E, Mitchell PH. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke 2009; 40: 2911–44.
Questions?