Hyperacute Stroke Management 20 May 2024.pptx

Management of Hyperacute stroke

1. WELCOME

2. MANAGEMENT OF HYPERACUTE STROKE Maj Dewan Mohaimenul Haque FCPS-II Trainee (Neurology) Dept of Neurology, CMH Dhaka

3. Case Report

4. Case Report A 60-year-old Female reported to E&C, CMH Dhaka with the complaints of chest pain. She was a patient of multiple valvular Heart disease with atrial fibrillation. She was labelled as Non-STEMI and was shifted to CCU. Following day patient developed sudden-onset Rt sided weakness with Aphasia. She was immediately attended by Neurologists. As initial CT scan of Brain was negative for ICH and NIHSS score was 10, she was thrombolysed with alteplase within an hour of onset. Subsequently, the weakness and aphasia improved. Later on, the after treatment of the cardiac issues, patient was discharged.

5. OUTLINE Introduction Milestones Definition Classification Evaluation Management

6. Introduction Over 2,000 years ago, physicians described this condition in the Hippocratic Corpus and gave it the name apoplexia   It was not until 1658 that Johann Jacob Wepfer , a physician practicing in Schaffhausen, Switzerland, identified the root causes of stroke.

7. Aim Stroke: An Overview Door to Needle Time IV Thrombolysis Various Trials and Recommendations AIM

8. Angiography Techniques CT Perfusion CT scan Carotid Doppler MRI 1927 1979 1983 1990 1975 8 Milestones in Cerebral Angiography

9. Recombinant Tissue plasminogen activator ( rTPA ) Endovascular Thrombectomy 1996 2015 9 Milestones in Hyperacute Stroke

10. STROKE: DEFINITION Stroke is a sudden-onset focal neurological deficit, non-traumatic, non-epileptic vascular in origin. A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts (or ruptures). When that happens, part of the brain cannot get the blood (and oxygen) it needs, so it and brain cells die.

11. STROKE: PATHOGENESIS

12. STROKE: CLASSIFICATIONS

13. STROKE: CLASSIFICATIONS

14. STROKE: CLASSIFICATIONS

15. STROKE: CLASSIFICATIONS

16. STROKE: CLASSIFICATIONS TOAST ( Trial of Org 10172 in Acute Stroke Treatment ) Classification

17. STROKE: CLASSIFICATIONS Sometimes known as “ warning strokes .” Warning sign of a future stroke Medical emergency , just like a major stroke More than a third of people who have a TIA and don’t get treatment have a major stroke within 1 year 10% to 15% of people will have a major stroke within 3 months of a TIA Transient Ischemic Stroke (TIA)

18. STROKE: STATISTICS

19. STROKE: STATISTICS

20. STROKE: PATHOGENESIS Stroke: A Battle Against the Biology of Nature

21. STROKE: PATHOGENESIS

22. PENUMBRA Rapid transfer to the stroke center will allow for protection of penumbra through emergency interventions and medical management. That tissue surrounding the blocked vessel that can be saved, but at risk.

23. Potential to Reverse Neurologic Impairment With Thrombolytic Reperfusion An untreated patient loses approximately 1.9 million neurons every minute in the ischaemic area Reperfusion offers the potential to reduce the extent of ischaemic injury Ischaemic core (brain tissue destined to die) Penumbra (salvageable brain area) PENUMBRA

24. T=0 Suspected stroke patient arrives at stroke unit ≤10 min Initial MD evaluation (including patient history, lab work initiation, & NIHSS) ≤ 15 min Stroke team notified (including neurologic expertise) ≤ 25 min CT scan initiated ≤ 45 min CT & labs interpreted ≤ 60 min rt -PA given if patient is eligible IDEALLY performed pre-hospital DTN* ≤60 min: the “ Golden Hour ” for evaluating and treating acute stroke DTN=Door to Needle Time

25. Role of Emergency Department in Stroke Management Emergency Department is the first contact point Symptom Identification Record Onset Time Medical History Lab work Initiation Initial Evaluation Inform Stroke Unit Inform Radiology GCS/NIHSS BP/BG Management Ideal Timeline – 15 Minutes from Patient Reaching to Emergency

26. Role of Emergency Department in Stroke Management All patients presenting to an Emergency Department with Suspected Acute Stroke or TIA must have: An immediate clinical evaluation Investigations to establish a diagnosis Rule out stroke mimics Determine eligibility for intravenous thrombolytic therapy

27. 2 3 1 4 An immediate clinical evaluation Investigations to establish a diagnosis Determine eligibility for intravenous thrombolytic therapy Rule out stroke mimics Role of Emergency Department in Stroke Management

28. Initial Evaluation Should have a rapid initial evaluation for airway, breathing and circulation A neurological examination to determine focal neurological deficits & assess stroke severity A standardized stroke scale should be used Like NIHSS Assessment in the acute phase should include heart rate and rhythm , blood pressure , temperature , oxygen saturation , hydration status , and presence of seizure activity Acute blood work should be conducted as part of the initial evaluation Initial blood work should include: electrolytes , random glucose , complete blood count (CBC), coagulation status (INR, aPTT ), and creatinine . Note: These tests should not delay imaging or treatment decisions and treatment initiation for intravenous thrombolysis

29. Initial Evaluation (Cont.) AHA/ASA Guideline on Initial Management of Stroke Patients

30. Initial Evaluation (Cont.) Key TIA/ Stroke symptoms Key   symptoms  that may be associated Weakness Sensory disturbance Visual disturbance Speech disturbance Ataxia Dysphagia Reduced level of consciousness Pain

31. Initial Evaluation (Cont.) Onset The  time  at which the patient’s symptoms developed is very important as this helps to both differentiate between a TIA and stroke as well as informing management options (e.g. thrombolysis window). Establish the  onset   time  of the patient’s symptoms: “When did you first notice the symptom(s)?” “How long have the symptom(s) been present?” If a patient has woken up with symptoms (but had none before going to sleep) the onset time is assumed to be when they went to sleep

32. Initial Evaluation (Cont.) Severity Explore the severity of the patient’s symptoms: Weakness: subtle (e.g. clumsy hand), moderate or complete paralysis Sensory disturbance: paresthesia or complete loss of sensation Visual disturbance: roughly quantify how much of the visual field is affected Expressive dysphasia: clarify if the patient was able to speak at all Receptive dysphasia: clarify if the patient is able to understand any communication Dysarthria: ask if the patient’s speech was mildly slurred or incomprehensible

33. Initial Evaluation Associated features Ask about other associated symptoms including: Headache , nausea , vomiting , neck stiffness : associated with raised intracranial pressure (e.g. malignant middle cerebral artery syndrome ), subarachnoid hemorrhage and bacterial meningitis Unilateral headache : suggestive of migraine which can present with neurological symptoms that mimic stroke (e.g. hemiplegic migraine ) Fevers : may indicate infective etiology such as septic emboli in infective endocarditis Nausea, vomiting and dizziness : associated with posterior circulation strokes Palpitations : associated with atrial fibrillation which may be the underlying embolic source

34. Initial Evaluation Associated features Headache, nausea, vomiting, neck stiffness associated with raised intracranial pressure (e.g. malignant middle cerebral artery syndrome ), subarachnoid hemorrhage and bacterial meningitis Unilateral headache suggestive of migraine which can present with neurological symptoms that mimic stroke (e.g. hemiplegic migraine ) Fevers may indicate infective etiology such as septic emboli in infective endocarditis Nausea, vomiting and dizziness associated with posterior circulation strokes Palpitations associated with atrial fibrillation which may be the underlying embolic source

35. Initial Evaluation Pain Ask the patient if they have any  pain : Explore the pain further using the  SOCRATES  acronym: S ite:  “Where is the pain?” O nset: “ When did the pain first start?” “Did the pain come on suddenly or gradually?” C haracter:  “How would you describe the pain?” R adiation:  “Does the pain spread elsewhere?” A ssociations:  “Are there any other symptoms that seem associated with the pain?” T ime course:  “How has the pain changed over time?” E xacerbating and relieving factors:  “Does anything make the pain worse or better?” S everity:  “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

36. Initial Evaluation: Pain S ite “Where is the pain?” O nset “ When did the pain first start?”  “Did the pain come on suddenly or gradually?” C haracter “How would you describe the pain?” R adiation “Does the pain spread elsewhere?” A ssociations “Are there any other symptoms that seem associated with the pain?” T ime course “How has the pain changed over time?” E xacerbating & relieving factors “Does anything make the pain worse or better?” S everity “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?” Ask the patient if they have any pain: Explore the pain further using the SOCRATES acronym:

37. Stroke Mimics & Stroke Chameleons

38. Stroke Mimics & Stroke Chameleons Stroke Mimics Stroke Chameleons Seizure Syncope S epsis M igraine Brain Tumor Bilateral Thalamic Stroke Limb Shaking TIA Critical carotid stenosis C ortical stroke Bilateral occipital strokes

39. Initial Evaluation: Seizure 2.5% – 5.7% Seizures are common during the early phase after a stroke and have been reported to occur with a frequency of 2.5% to 5.7% within 14 days after a stroke, based on the territory and nature of stroke. New-onset seizures (at onset/ immediately before/ within 24 hours of the stroke) appropriate short-acting medications (e.g. lorazepam IV) A single, self-limiting seizure (“immediate” post-stroke seizure) No need of long-term anticonvulsant After an immediate post-stroke seizure should be monitored for recurrent seizure activity Incase of immediate post-stroke seizure Prophylaxis is not recommended

40. Acute Blood Pressure Management Ischemic stroke patients eligible for thrombolytic therapy Very high blood pressure (greater than 185/110 mm Hg) should not be treated concurrently with thrombolysis to reduce the risk of hemorrhagic transformation Blood pressure should be lowered and sustained below 185/110 prior to alteplase therapy and to below 180/105 mmHg for the next 24 hours after alteplase administration Ischemic stroke patients not eligible for thrombolytic therapy : Treatment of hypertension in the setting of acute ischemic stroke or transient ischemic attack should not be routinely treated Blood Pressure lowering drugs should be used to achieve the target BP. Emergency Department can play a crucial role to achieve that without losing time.

41. AHA/ASA Guideline on BP Management Patient otherwise eligible for emergency reperfusion therapy except that BP is >185/110 mmHg: Labetalol 10–20 mg IV over 1–2 min, may repeat 1 time; or Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5–15 min, maximum 15 mg/h; when desired BP reached, adjust to maintain proper BP limits; or Clevidipine 1–2 mg/h IV, titrate by doubling the dose every 2–5 min until desired BP reached; maximum 21 mg/h Other agents ( eg , hydralazine, enalaprilat ) may also be considered If BP is not maintained ≤185/110 mmHg, do not administer alteplase Management of BP during and after alteplase or other emergency reperfusion therapy to maintain BP ≤180/105 mmHg: Monitor BP every 15 min for 2 h from the start of alteplase therapy, then every 30 min for 6 h, and then every hour for 16 h If systolic BP >180–230 mmHg or diastolic BP >105–120 mmHg: Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min; or Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 min, maximum 15 mg/h; or Clevidipine 1–2 mg/h IV, titrate by doubling the dose every 2–5 min until desired BP reached; maximum 21 mg/h If BP not controlled or diastolic BP >140 mmHg, consider IV sodium nitroprusside

42. Temperature Management AHA/ASA Guideline on Temperature Management of Stroke Patients

43. Blood Glucose Management AHA/ASA Guideline on Blood Glucose Management of Stroke Patients Hypoglycemia ( blood glucose <60 mg/dl should be treated in patients with AIS Evidence indicates that persistent in-hospital hyperglycemia during the first 24 hours after AIS is associated with worse outcomes than normoglycemia , and thus, it is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/ dL and to closely monitor to prevent hypoglycemia in patients with AIS.

44. Additional Management Considerations Chest X-Ray: Should be completed when the patient has evidence of acute heart disease or pulmonary disease. Unless a patient is hemodynamically unstable, chest x-ray can be deferred until acute treatment & it should not delay assessment for thrombolysis Swallowing Assessment: Patient swallowing screen should be completed as early as possible as part of initial assessment But should not delay decision-making regarding eligibility for acute stroke treatments

45. Additional Management Considerations Gugging Swallowing Screen This screen can be used to perform Swallow test

46. Treatment Options for AIS Thrombolysis Mechanical Thrombectomy

47. History & Physical Examination to include: Confirm history with patient, family, witnesses with particular reference to: Stroke onset time Medical history (DM, HTN, IHD, Previous Stroke/MI, Liver Disease, Renal Impairment) Advance care directive/refusal of life sustaining treatment/outcomes to avoid Medication (OAC, Heparin) Previous surgery or bleeding history Allergies Identify any potential bleeding source Obtain and document all results (i.e. ECG, blood tests, Vital signs) Review CT scan with radiology staff & immediately discuss with stroke consultant. ALTEPLASE IS CONTRAINDICATED IN HAEMORRHAGIC STROKE CT SCAN SHOULD BE PERFORMED TO RULE OUT HAEMORRHAGIC STROKE OR ANY BLEEDING IN BRAIN BEFORE USING ACTILYSE

48. Exclusion Criteria For rTPA

49. Exclusion Criteria For rTPA

50. ALTEPLASE DOSING

51. Administration of timely thrombolysis with rt -PA Saver J. Stroke 2006;37:263-266. The European Stroke Organisation (ESO) Executive Committee and the ESO Writing Committee. Cerebrovasc Dis 2008;25(5):457-507. Powers WJ, et al. Stroke 2018;49(3):e46-e110. The stroke team should strive to keep the door-to-needle time to less than 60 minutes 2,3 The time window for IV thrombolysis is up to 4.5 h after onset of symptoms in eligible patients 2,3 Time is brain: the earlier reperfusion is established, the greater the chance of reducing ischaemic injury 1-3 Time is brain

52. Treatment Options for AIS

53. T=0 Suspected stroke patient arrives at stroke unit ≤10 min Initial MD evaluation (including patient history, lab work initiation, & NIHSS) ≤ 15 min Stroke team notified (including neurologic expertise) ≤ 25 min CT scan initiated ≤ 45 min CT & labs interpreted ≤ 60 min rt -PA given if patient is eligible IDEALLY performed pre-hospital DTN * ≤60 min : the “ Golden Hour ” for evaluating and treating acute stroke DTN=Door to Needle Time

54. AIS patients treated with rt-PA are 30% more likely to have minimal or no disability at three months 1 Over a 10-year period, a patient treated with thrombolysis lives on average 1 year longer than a similar non- thrombolysed patient 2 National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995;333(24):1581-1587. Muruet W, et al. Stroke 2018;49(3):607-613. Patient outcomes of alteplase ( rt -PA) treatment of AIS

55. NINDS rt-PA study IV Alteplase vs Placebo, 1991-1994, 624 patients Given to patients within 3-hours from their last known well

56. ECAS- III IV Alteplase vs Placebo, 821 patients, 18-80 yrs Given to patients within 4.5-hours of stroke onset

57. POINT & CHANCE Trials: Dual Antiplateler in Mild Stroke POINT: Platelet-Oriented Inhibition in New TIA and Minor Ischemic Strokes CHANCE: Clopidogrel in High-risk patients with acute Non-disabling Cerebrovascular events

58. ECAS- III IV Alteplase vs Placebo, 821 patients, 18-80 yrs Given to patients within 4.5-hours of stroke onset

59. NINDS Trial The NINDS trial was a randomized, double-blind, placebo-controlled trial of patients with acute ischemic stroke treated with Activase or placebo within 3 hours of stroke symptom onset. The trial was carried out in 2 parts: Part 1 (n=291) assessed changes in neurologic deficits 24 hours after the onset of stroke Part 2 (n=333) assessed clinical outcomes at 90 days

60. Clinical Outcomes long-term clinical benefit of t-PA predicted by the results 55 % more likely to have minimal or no disability at three months NIH = National Institutes of Health Scores of ≤ 1 on the NIHSS, 95 to 100 on the Barthel Index, ≤ 1 on the modified Rankin scale, and 1 on the Glasgow outcome scale were considered to indicate a favourable outcome NINDS rt -PA Stroke Study Group. N Engl J Med 1995; 333: 1581-1587.

61. Safe Implementation of Treatments in Stroke (SITS)

62. https://www.sitsinternational.org/media/1470/sits-report-2019_final-for-print.pdf/acessed 5th Sep, 2020 Due to Better Patient choice outcome is better and hemorrhage is reducing SITS registry Outcome data (2019)

63. Thrombolysis – Beyond the Window Meta-analysis of EPITHET, ECASS-4 and EXTEND 36% patients achieved excellent outcome in the meta-analysis 3 predefined time Onset Patients were here 4.5–6 h 6–9 h Wake-Up Stroke

64. Pooled Data is still favoring Alteplase European Stroke Organization (ESO) New data for Alteplase vs Tenecteplase

65. European Stroke Organization (ESO) New data for Alteplase vs Tenecteplase

66. Guideline Recommendations for IV Thrombolysis

67. Recommendation by ASA for IVT Benefit of IV Alteplase well established in RCTs and confirmed by extensive experience Alteplase is beneficial regardless of age and stroke severity Wake-Up: IV Alteplase administered within 4.5 hours of stroke symptom recognition or beyond 4.5 hours have been proven to be beneficial and who have a DW-MRI lesion smaller than one-third of the middle cerebral artery (MCA) territory and no visible signal change on FLAIR. Ref; Powers, William J., et al. "Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association."  Stroke  50.12 (2019): e344-e418. ASA: American stroke association IVT: IV Thrombolysis

68. Recommendation for IV Alteplase Ref; Powers, William J., et al. "Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association."  Stroke  50.12 (2019): e344-e418. ASA: American stroke association IVT: IV Thrombolysis

69. Take Home Message