Update on Stroke
Management
Live from JJ Baumann MS, RN, CNS
Ischemic Stroke
Focus on providing treatment
quickly!
Patients get treatment faster if :
Stroke severity is high
Arrive by ambulance
Arrival 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
Not FDA approved!
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
diabetes
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 trial
Raul 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 trial
Jeffrey L Saver, Reza Jahan, Elad I Levy,
Tudor G Jovin, Blaise Baxter, Raul G
Nogueira, Wayne Clark, Ronald Budzik,
Osama O Zaidat, for the
SWIFT Trialists
Lancet 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
Phase 2 trial
Promising results:
ICH volume smaller
35% reduction in mortality
Less disability
Slightly more clotting events (e.g. PE’s ,DVT, MI’s)
Phase 3 trial
Effective
No change in mortality or morbidity
Prothrombin Complex Concentrate (PCC) is
preferred over rFVIIa.
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 in
patients with spontaneous supratentorial lobar intracerebral
haematomas (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
Too much
pressure these
vessels will burst
or bleed more
Need enough
pressure for injured
area to get blood
from other vessels
Intracranial Hemorrhage: Current BP
Guidelines
Class IIa Recommendation “In favor of”
• SBP 150 – 220 lower SBP to 140
Class 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
Critical
Care
Medicine
Supporting Self
Management
NeuroIR,
Physiatry,
Therapist
Vascular,
Rehab,
Stroke RNs
EVDs, tx of
AVM, aSAH
NIR
NSurg
Program
Management
Leadership,
Care Level
Access to SHC
IV tPA
Comprehensive
Primary Stroke
Stroke
Care Center
Center
Education to
OSH
Research
Clinical
Information
Management
CSC specific
resources
Delivering/
Facilitating
Clinical Care
Radiology
Patient
Outcomes
Education/
info sharing
8 metrics
Performance
Improvement/
Measurement
Meaningful
Use
26 metrics
Neuro
Critical
Care
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
Need Lower
Low perfusion in brain
- tight ICA, MCA
Stroke not completed
Completed their stroke
***Does the neuro exam
decline with decreased BP?
***Slow and steady!
At risk of bleeding
Imaging
•
•
•
•
CT
MRI
TTE
TEE
Stroke Certification for Nurses
Stroke Certified Registered
Nurse (SCRN)
ANVC Certification Exams
(NVRN-BC) & (ANVP-BC)
American Board of Neuroscience
Nursing (ABNN) exam
Neurovascular Registered Nurse Board Certified
Advanced Neurovascular Practitioner
- Board Certified
Through American Association of
Neuroscience Nurses
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?