Management of Acute Ischemic Stroke and
Transitory Ischemic Attack
Time is still Brain
Victoria Parada MD
Clinical Director
Neuroscience and Stroke Program
Valley Baptist Medical Center Harlingen
Objectives
• Address opportunities for optimal care in the acute phase of ischemic
stroke through:
• A review of latest scientific guidelines from the American Stroke
Association published in March 2013 for the treatment of acute ischemic
stroke
(US Food and Drug Administration approved and
evidence-based care, including IV thrombolysis with recombinant tissuetype plasminogen activator)
• A review of the new recommendations and safety of ivTPA administration
to patients where the treatment was previously contraindicated
• A review of the role of Primary and Comprehensive Stroke Centers in the
Community and the role of Regional Stroke Systems of Care
STROKE AN EQUAL OPPORTUNITY DISEASE
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IN THE USA ON AVERAGE SOMEONE SUFFERS A STROKE
EVERY 45 SECONDS
795,000 AMERICANS HAVE STROKES ANNUALLY, 200,000 500,000 PRESENT WITH TIA
185,000 PATIENTS SUFFER A RECURRENT STROKE
STROKE DECLINES FROM 3RD TO 4TH LEADING CAUSE OF
DEATH IN THE USA
BY 2008 STROKE MORTALITY RATE WAS 75% LESS THAN 19311960 RATE
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STROKE REMAINS THE LEADING CAUSE OF
DISABILITY IN THE USA
TRADE OFF MORTALITY REDUCTION THROUGH BETTER
ACUTE STROKE CARE IS AN INCREASE IN SURVIVORS WITH
POST-STROKE CONSEQUENCES
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ESTIMATED $73.7 BILLION IN ECONOMIC COSTS (2010)
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INCALCULABLE HUMAN AND SOCIAL COST TO
PATIENTS AND FAMILIES
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TIA AND ACUTE ISCHEMIC STROKE
• TIA is a brief episode of neurological dysfunction caused by a
focal disturbance of brain or retinal ischemia, which clinical
symptoms typically lasting less than 60 minutes and without
evidence of infarction
• STROKE any neurological dysfunction caused by a focal
disturbance of brain or retinal ischemia lasting longer than 60
minutes with radiological evidence of infarction
•87
% Ischemic
•10 % Hemorrhagic
• 3 % SAH
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How do we translate these
information into daily clinical practice?
• The first goal of evaluation is to confirm that patient’s symptoms are due
to ischemic stroke
• Second the urgent evaluation helps determine advisability for acute
treatment with thrombolytic agents
• Third, diagnostic studies are carried out to screen for acute medical or
neurological complications of stroke
• Fourth, the evaluation provides historical data useful to establish the
vascular distribution of the stroke and provide clues about its etiology
• Fifth, these data are essential to make decisions about optimal
secondary stroke prevention
EMS
ER STAFF
STROKE
CODE
TEAM
COMUNITY
REHAB
SERVICES
STROKE UNIT/ NICU
STROKE CHAIN OF SURVIVAL
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Detection
early recognition AIS and TIA symptoms
Dispatch
IMMEDIATE ACTIVATION 911 and priority EMS
Delivery
Prompt transport TO MOST APPROPRIATE STROKE
HOSPITAL and prehospital notification
Door
Immediate ER triage to HIGH ACUITY AREA
Data ER evaluation, STROKE TEAM ACTIVATION, laboratory, and
brain imaging
Decision
Diagnosis and determination of most appropriate
therapy, DISCUSSION WITH PATIENT /FAMILY
Drug
Administration of appropriate drugs or other
interventions
Disposition TIMELY admission to STROKE UNIT OR NICU
PREHOSPITAL EVALUATION
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Asses and manage ABC’s
Initiate cardiac monitoring
Provide supplemental Oxigen to mantain O2 saturation >94%
Establish IV access per local protocol
Determine blood glucose and treat accordingly
Determine time of symptom onset or last known normal, family
contact
TRIAGE AND RAPIDLY TRANSPORT TO THE CLOSEST
AVAILABLE CERTIFIED PRIMARY OR COMPREHENSIVE
STROKE CENTER
Comprehensive
Primary
Acute Stroke Ready
Highly specialized treatments
for ALL types of strokes
Research
Wide range of hospitals
ivTPA, Stroke Units
Standard Stroke Care
Telemedicine
Drip and Ship Protocol
BENEFITS
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PSC increased the use of IV tPA from 1.5 % to
10.2%
CSC increased the use of lytic agents and improved
overall care and outcomes for ISCHEMIC STROKE,
INTRACRANIAL BLEEDS AND SUBARACHNOID
HEMORRHAGE
In hospital deaths are reduced by almost 50 % in
hospitals with vascular neurologists and
multidisciplinary neuroscience critical team
In hospital deaths are reduced by 24 % in hospitals
with a stroke team, stroke units and neuro critical
EMERGENCY EVALUATION AND DIAGNOSIS OF
ACUTE ISCHEMIC STROKE
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Timely evaluation and diagnosis are paramount
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ER most have an efficient pathway to identify and evaluate potential stroke
patients
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Patients with suspected acute stroke should be triaged with same priority than
serious trauma or MI, regardless of severity of deficits
PROCESS OF CARE FROM SYMPTOM ONSET
GOAL 60 MINUTES FROM DOOR TO NEEDLE
ED ARRIVAL
MD EVAL
0 min
<10 min
STROKE TEAM
<15 min
CT
<25 min
CT READ
< 45 min
tPA bolus
<60 minuts
Door to STROKE UNIT OR NICU ADM
< 3 HOURS
Acute stroke therapy
• Accurate time of symptom onset
• Focused bedside assessment
• Rapid interpretation of ancillary tests
Neurologic Examination
• The examination should focus on
identifying signs of lateralized
hemispheric or brainstem dysfunction
consistent with focal cerebral ischemia
(NIHSS)
Ancillary Testing
• blood glucose
• electrolytes
• complete blood count
• prothrombin time
• activated partial thromboplastin time,
• international normalized ratio
• renal function
• cardiac enzymes and a 12-lead EKG
CT of brain w/o contrast
• Early signs of ischemic stroke:
• Hyper-dense vessel sign
• Loss of insular ribbon
• Obscuration of lenticular nucleus
• Loss of gray-white matter distinction
• Sulcal effacement
• Areas of hypo-attenuation
• Non invasive vascular study is strongly
recommended during initial evaluation if
mechanical thrombectomy is
contemplated
• CT perfusion for measurements of
infarct core and penumbra is
recommended for selection of acute
reperfusion therapy beyond 3 hours
RECOMMENDATIONS FOR PATIENTS WITH
SYMPTOMS OF AIS THAT HAVE RESOLVED
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Non invasive imaging of cervical vessels
CTA or MRA of intracranial vasculature to exclude the presence of
proximal intracranial stenosis or oclussio. Confirmation with catheter
angiography is recommended.
PATIENTS WITH TIA SHOULD UNDERGO NEUROIMAGING
EVALUATION WITHIN 24 HOURS FROM SYMPTOMS ONSET
Intravenous rTPA
• IV thrombolytic therapy remains the
cornerstone of evidence-based acute
ischemic stroke therapy (Class I; level
A)
• IV rt-PA is efficacious and cost-effective
for patients with acute ischemic stroke
treated within 3 hours of symptom onset
• 6.6% complication of symptomatic
intracranial hemorrhage (sICH)
iv TPA NNT
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4.5 for 0 -90 minutes
9.0 for 91-180 minutes
14.1 for 181-270 minutes
21.4 for 271-360 minutes
DOOR TO NEEDLE TIME <60 MINS
(Class I; level A)
The above figure demonstrates that the likelihood of a favorable clinical outcome
diminishes as time to the initiation of IV rt-PA initiation increases.
This model was derived from a pooled analysis of major IV rt-PA strokes trials-the
ATLANTIS Parts A and B, ECASS I and II, and National Institute of Neurological
Disorders and Stroke Parts I and II trials-after adjustment for age, baseline glucose
concentration, baseline National Institutes of Health Stroke Scale (NIHSS) score,
baseline diastolic blood pressure, history of hypertension, and interaction between
age and baseline NIHSS measurement.
3 to 4.5 hours window
(Class I; Level B)
• Compared with the NINDS rt-PA trial the
design of ECASS III had three notable
differences in exclusion criteria:
• (1) Exclusion criteria included age
greater than 80 years
• (2) Severe stroke (NIHSS score greater
than 25)
• (3) History of diabetes with prior stroke
Inclusion and Exclusion characteristics of
Patients AIS who could be treated with IV tpa
within 3 hours from symptom onset
• Inclusion criteria
• Diagnosis of AIS causing measurable
neurological deficit
• Onset of symptoms < 3hours before
beginning treatment
• Age >18 or older
Exclusion Criteria
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Significant head trauma or prior stroke in the last 3 months
Symptoms suggest SAH
Arterial puncture in non compressible site <7 days
History of previous ICH
Intracranial neoplasm, AVM or aneurysm
Recent intracranial or intraspinal surgery
Elevated BP (SBP >185 or DBP> 110 mm Hg)
Active internal bleeding
Platelet count <100,000
Heparin received <48 hours resulting in elevated PTT
Current use of anticoagulant with INR >1.7 or PT >15 secs
Current use of Direct Thrombin inhibitors or factor Xa inhibitors
Blood glucose concentration <50 mg/dl
CT with multilobar infarction (> 1/3 of cerebral hemisphere)
RELATIVE EXCLUSION CRITERIA
Class IIB; level C
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CONSIDER RISK TO BENEFIT OF IVrTPA ADMINSTRATION
CAREFULLY IF ANY OF THESE RELATIVE CONTRAINDICATIONS
EXISTS:
• MINOR OR RAPIDLY IMPROVING
SYMPTOMS
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SEIZURE AT ONSET WITH POST ICTAL IMPAIRMENTS
MAJOR SURGERY OR SERIOUS TRAUMA <14 DAYS
RECENT GI OR URINARY TRACT HEMORRHAGE <21 DAYS
RECENT ACUTE MI <3 MONTHS
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BMJ 2004;328;326
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“1/3 of patients
who are not
treated with
IVrTPA due to
mild or rapid
improvement of
symptoms will
have a poor final
stroke outcome”
Neurology.2009 Jun2;72(22):1941-7
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LESSONS LEARNED...
•Acute ischemic stroke is typically a clinical diagnosis.
•A noncontrast CT scan is necessary to exclude intracranial hemorrhage.
When the diagnosis is unclear, additional neuroimaging studies, such as
MRI or CT angiography, may be helpful
•Minor or isolated symptoms typically are not treated However, treating
isolated disabling symptoms, such as aphasia, is reasonable.
•If the exact time of symptom onset cannot be determined, then the time
the patient was last seen to be normal should be substituted for the time
of symptom onset
Notes on specific eligibility criteria
•The finger-stick blood glucose level should be reviewed during the
eligibility evaluation
•It is reasonable to proceed with IV rt-PA administration prior to obtaining
coagulation results if there is no clinical suspicion of a potential abnormality
and awaiting theses results would delay treatment
•Ask about use of new anticoagulants, use in last 48h may limit use of iv
TPA administration
•Treatment in the setting of myocardial infarction is often a consideration in
consultation with cardiology
•Stroke patients with recent surgery may be considered for thrombolysis or
Endovascular thrombectomy if available at experienced center
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Catheter guided endovascular
interventions
Patients elegible for IVrTPA should receive it even if endovascular
treatments are being considered (Class I; Level A)
As with IVrTPA reduced TIME from symptom onset to reperfusion
therapy is highly correlated with better outcomes (Class I; level B)
Stent retrievers such as Solitaire FR and Trevo are preferred for coil
retrievers over the Merci device when mechanical thrombectomy is
used (Class I; Level A)
Intra-arterial therapy or mechanical thrombectomy is reasonable in
patients who have contraindications for IVrTPA (Class IIa, level C)
Rescue intra-arterial therapy or mechanical thrombectomy may be
reasonable approaches to recanalization to patients with large
artery occlusion and no response to IVrTPA (Class IIb; level B)
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IV r TPA administration protocols
Class I; Level B
Infuse at 0.9mg/kg max dose 90 mg over 60 min, 10% dose bolus
Admit to NICU or Stroke Unit for monitoring
If severe headache, acute peak hypertension, nausea or vomiting, or
worsening of neurological exam, discontinue infusion and obtain
STAT CT
Measure blood pressure and perform assessments every 15 min
during infusion and after two hours, every 30 min for 6 hours, then
hourly until 24 hours completed
Increase frequency of BP monitoring if SBP>180 or DBP>105,
administer IV blood pressure medicines as per protocol to maintain
below that range
Delay placement of NG tubes, indwelling catheters
Follow up CT or MRI of brain w/o at 24 h post IVrTPA
Have protocols for STAT assessment and treatment of symptomatic
ICH or angiodema
Action Points!!!
• TIME = BRAIN
• DOOR TO NEEDLE TIME <60 MIN
• REGIONAL STROKE NETWORKS
• EXPANDED ELIGIBILITY FOR IVrTPA
• ENDOVASCULAR TREATMENTS
MAY BENEFIT SELECTED PATIENTS
• MULTIDISCIPLINARY TEAM
APPROACH FAVORS PATIENTS
OUTCOMES
Valley Baptist
Neuroscience Team