STROKE
Presented by
Robert Nelson BSN, MBA, MHA, SCRN, CNRN, ONC
Vice President Neuroscience and Orthopedics
HCA East Florida Division
OBJECTIVES

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.
Stroke Epidemiology
and Risk Factors
Stroke





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.
Stroke Facts

A 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
Stroke 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
Non-modifiable Risk Factors
Sacco RL, et al. Stroke. 1997;28:1507-1517.

Age

Gender

Race/ethnicity

Heredity
Women & 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
African 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
Hispanics & 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 Englishspeaking Hispanics, African Americans and
Caucasians
Stroke Risk Factors:
Modifiable/Lifestyle

Hypertension

Excessive alcohol use

Cigarette smoking

Cocaine and IV drug use

Hypercholesterolemia

Physical inactivity

Hyperlipidemia

Oral contraceptive use
Potentially Treatable or
Modifiable
Risk Factors for Stroke

Heart disease (MI,
CHF, PFO)

Diabetes

Menopause

Obesity

Atrial fibrillation

Prior stroke or TIA

Carotid artery
disease

Elevated homocysteine
level

Sickle cell anemia


High RBC count
Low socioeconomic
status
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
Evaluation of Stroke

History and Physical

Diagnostic tests

Brain parenchyma

Vascular system
Brain Attack!

Stroke is a “Brain
Attack.”

Stroke happens in the
brain not the heart

Stroke is an emergency.
Call 911 for emergency
treatment.
15
Definition 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)
Embolic
Hemorrhagic = Bleed
- Bleeding around brain
- Bleeding into brain
Thrombotic
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
American Heart Association. Heart Disease and Stroke Statistics—2003 Update.
 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
TIA




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
Blood Tests

rt-PA Candidates




CBC, blood glucose,
chemistry, PT, INR,
and PTT

HgbA1c

Sickle cell disease

Hypercoagulation
work-up

Sedimentation rate

ANA
Cardiac Enzymes
Homocystein
Fasting Lipid Profile
Evaluation of Brain Parenchyma
MRI
CT
Images courtesy of
Regional Neurosciences Unit, Newcastle General Hospital,
Newcastle, UK.
Vascular Tests
Noninvasive

CT




CTA


R/O bleed
R/O other conditions
Identify early changes that would indicate
poor rt-PA outcome
To identify clots that could be treated with
IA rt-PA
MRI

Confirms area of infarct with-in a few hours
of the infarct
Vascular Tests
Non 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
Evaluation of the Vascular System
Intracranial
atherosclerosis
Carotid plaque with
arteriogenic emboli
Aortic arch
plaque
Cardiogenic
emboli
Penetrating artery
disease
Flow-reducing
carotid stenosis
Atrial fibrillation
Valve disease
Left ventricular
thrombi
Reprinted with permission from Albers GW, et al. Chest. 2001;119:300S-320S.
Heart Tests

12-Lead ECG

Telemetry

Echocardiography

TTE

TEE
Aortic 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.
TREATMENT

Thrombolytic therapy ACTIVASE, tPA, Alteplase

Aspirin

Blood pressure management

Secondary prevention

ASA, antiplatelets

Anticoagulation

Prevention of complications

Rehabilitation
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
Acute Stroke Treatments
Ischemic stroke (Brain Clot)
Clot busting medication: t-PA (Tissue
Plasminogen Activator)
Clot-removing devices: Merci Retriever,
Penumbra
Hemorrhagic Stroke (Brain Bleed)
Clipping
Coiling
Current 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
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
Exclusion Criteria – rt-PA

Medications that might increase bleeding?


Exam findings – high risk of bleeding



Anticoagulants
Systolic BP > 185
Diastolic BP > 110
Lab findings – high risk of bleeding


Prolonged INR, PTT
Thrombocytopenia
Exclusion 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
Current Usage rt-PA
 Under Usage of rt-PA at Stroke Centers: 1% to 3%

Estimate is that 10% of eligible patients should
receive rt-PA

The most frequent reason rt-PA is not given is
the patient presents outside the 3 hr. window

Patient and Community Education Critical
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
BP Recommendations for Ischemic Stroke
Patients Eligible for Thrombolysis

Before rt-PA treatment

Systolic > 185 or diastolic > 110


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
Labetalol
Aim for 10%-15% reduction in BP
BP Recommendations for Ischemic Stroke
Patients Not Eligible for Thrombolysis

Systolic < 220 or diastolic < 120



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


Observe unless other end-organ involvement
Nitroprusside
Aim for 10%-15% reduction in BP
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
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
New Treatments

Combined IV and IA Thrombolytics

Clot Retrieval Devices

Neuro-protective Agents

Hypothermia

Hyperbaric Oxygen
Surgical Options
Decompressive 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
Acute 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
Stroke 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
Types 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
Types 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
Secondary Prevention of Stroke
and Other Vascular Events
Secondary 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
Blood Pressure Control Is
Inadequate in the US
Millions of People
23
13
13.5
Unaware
Untreated
Inadequately treated
140/90 mm Hg
Arch Intern Med. 1997;157:2413-2446. JNC-IV. Trilling JS, Froom J. Arch Fam Med. 2000;9:794-801.
16
Secondary Prevention of Stroke:
Percentage Prevented per Year
% of strokes prevented/yr
0
Antihypertensives
Clopidogrel vs. ASA
Warfarin
Statins
Smoking Cessation
Aspirin
Carotid Endarterectomy
Straus SE, et al. JAMA. 2002;288:1388-1395.
2
4
6
8
10 12 14 16 18
Modifiable Risk Factors and
Preventable Strokes
Risk Factor
Projected strokes
prevented*
Hypertension
360,000
Smoking
90,000
Atrial Fibrillation
69,000
Heavy Alcohol
Consumption
34,000
*Based on 731,000 strokes.
Adapted with permission from Gorelick PB. Stroke. 1994;25:220-224.
Biblography/ References



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