latest trends in care of the stroke patient william j. meurer, md clinical lecturer and stroke...
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Latest Trends in Care Latest Trends in Care of the Stroke Patient of the Stroke Patient
William J. Meurer, MDWilliam J. Meurer, MDClinical Lecturer and Stroke FellowClinical Lecturer and Stroke Fellow
University of Michigan Stroke ProgramUniversity of Michigan Stroke ProgramDepartments of Emergency Medicine Departments of Emergency Medicine
and Neurologyand Neurology
ObjectivesObjectives
Review concise clinical pearls in Review concise clinical pearls in caring for the acute stroke patientcaring for the acute stroke patient
Review results of past research that Review results of past research that may influence your practicemay influence your practice
Discuss recently announced acute Discuss recently announced acute stroke researchstroke research
Provide overview of ongoing research Provide overview of ongoing research which may influence your practice in which may influence your practice in futurefuture
DisclosuresDisclosures
My salary is provided by the My salary is provided by the University of MichiganUniversity of Michigan
No other financial supportNo other financial support I WILL discuss some off label uses of I WILL discuss some off label uses of
medicationsmedications
OverviewOverview
Review scope and disease process of Review scope and disease process of stroke stroke
Review clinical guidelines and pearlsReview clinical guidelines and pearls Discuss recent advancesDiscuss recent advances Discuss ongoing national and local Discuss ongoing national and local
researchresearch
Stroke Facts
• Third leading cause of death– Over 160,000 deaths per year
• 750,000 strokes per year• Over 4 million stroke survivors• Leading cause of adult disability
– Of those who survive, 90% have deficit
1. Williams GR, J iang J G, Matchar DB, et al. Stroke 1999; 30:2523-28.2. Hoyert DL, Kochanek KD, Murphy SL. National Vital Statistics Report 1999; 47:19.
Annual rate of first cerebral infarction by age, sex and race Annual rate of first cerebral infarction by age, sex and race
(Greater Cincinnati/Northern Kentucky Stroke Study: 1993-94).(Greater Cincinnati/Northern Kentucky Stroke Study: 1993-94). Source: Unpublished data from the GC/NKSS; Kissela et al., Stroke. 2004;35:426-31. Source: Unpublished data from the GC/NKSS; Kissela et al., Stroke. 2004;35:426-31.
Smoothed County Stroke Death Rates: Smoothed County Stroke Death Rates: Adults 35 and Older, 1991-98Adults 35 and Older, 1991-98
Source: CDC. Atlas of Stroke Mortality: Racial, Ethnic and Geographic Disparities in the United States, Jan. 2003
Acute Stroke / ASA GuidelinesAcute Stroke / ASA Guidelines
tPA if indicated and exclusions tPA if indicated and exclusions absentabsent
Anti-platelet within 48 hours (do not Anti-platelet within 48 hours (do not give with tPA)give with tPA)
Permissive hypertensionPermissive hypertension No IV anticoagulants (i.e. heparin) – No IV anticoagulants (i.e. heparin) –
DVT prophylaxis okay (after 48 hr if DVT prophylaxis okay (after 48 hr if tPA given)tPA given)
CT remains standard acute imagingCT remains standard acute imaging
ASA guidelines – ischemic strokeASA guidelines – ischemic stroke
If not receiving thrombolyticsIf not receiving thrombolytics– Do not treat unless SBP > 220 or DBP > Do not treat unless SBP > 220 or DBP >
120120 If receiving thrombolytics treat ifIf receiving thrombolytics treat if
– PreRx SBP > 185 DBP > 110 PreRx SBP > 185 DBP > 110 – PostRx SBP > 180 DBP > 105PostRx SBP > 180 DBP > 105
Doesn’t ACEP also have a Doesn’t ACEP also have a guideline?guideline?
Has practice guidelineHas practice guideline www.acep.org – type acute stroke www.acep.org – type acute stroke
into search boxinto search box I recommend you read it yourselves I recommend you read it yourselves
if interestedif interested
Copied from ACEP website Copied from ACEP website verbatimverbatim
EDs and hospitals should work with EDs and hospitals should work with emergency medical services and the emergency medical services and the community so that all parties know community so that all parties know what the hospital's capabilities are what the hospital's capabilities are regarding acute stroke care.regarding acute stroke care.
Further studies are needed to define Further studies are needed to define more clearly those patients most more clearly those patients most likely to benefit from fibrinolytic likely to benefit from fibrinolytic therapy in acute ischemic stroke.therapy in acute ischemic stroke.
Copied from ACEP website Copied from ACEP website verbatimverbatim
Intravenous tPA may be an Intravenous tPA may be an efficacious therapy for the efficacious therapy for the management of acute ischemic management of acute ischemic stroke if properly used incorporating stroke if properly used incorporating the guidelines established by the the guidelines established by the National Institute of Neurological National Institute of Neurological Disorders and Stroke (NINDS).Disorders and Stroke (NINDS).
Copied from ACEP website Copied from ACEP website verbatim (bolding mine)verbatim (bolding mine)
There is insufficient evidence at this time to There is insufficient evidence at this time to endorse the use of intravenous tPA in clinical endorse the use of intravenous tPA in clinical practice practice when systems are not in place to when systems are not in place to ensure that the inclusion/exclusion criteria ensure that the inclusion/exclusion criteria established by the NINDS guidelines for tPA established by the NINDS guidelines for tPA use in acute stroke are followeduse in acute stroke are followed. Therefore, . Therefore, the decision for an ED to use intravenous tPA for the decision for an ED to use intravenous tPA for acute stroke should begin at the institutional level acute stroke should begin at the institutional level with commitments from hospital administration, with commitments from hospital administration, the ED, neurology, neurosurgery, radiology, and the ED, neurology, neurosurgery, radiology, and laboratory services to ensure that the systems laboratory services to ensure that the systems necessary for the safe use of fibrinolytic agents necessary for the safe use of fibrinolytic agents are in place.are in place.
A. Hernandez, M.I. Rochera, R. Angles, M. Farre, J. Caballero: Hemorrhagic Transformation And A New Ischemic Accident During Thrombolysis Treatment With rtPA. The Internet Journal of Emergency and Intensive Care Medicine. 2006. Volume 9 Number 1
Acute stroke - summaryAcute stroke - summary
Time is brain (notify, notify, notify)Time is brain (notify, notify, notify) tPA is your friendtPA is your friend Watch for fluctuationWatch for fluctuation Treat feverTreat fever Consider treating hyperglycemiaConsider treating hyperglycemia Use crystalloid (think perfusion)Use crystalloid (think perfusion) Avoid dropping BP in ischemic strokeAvoid dropping BP in ischemic stroke Acute Stroke Protocol in place and Acute Stroke Protocol in place and
ready to go! ready to go!
Important advance – primary stroke Important advance – primary stroke centerscenters
Acute Stroke TeamsAcute Stroke Teams Written Care Protocols Written Care Protocols Emergency Medical ServicesEmergency Medical Services Emergency DepartmentEmergency Department Stroke UnitStroke Unit Neurosurgical ServicesNeurosurgical Services Support of Medical OrganizationSupport of Medical Organization Neuroimaging Neuroimaging Laboratory ServicesLaboratory Services Outcomes/Quality Improvement Outcomes/Quality Improvement Education ProgramsEducation Programs
Primary Stroke Centers (JCAHO)Primary Stroke Centers (JCAHO)Bixby Medical Center
Borgess Medical Center
Bronson Methodist Hospital
Detroit Receiving Hospital/University Health Center
Henry Ford Hospital and Health Network
Herrick Memorial Hospital
Metro Health Hospital
Northern Michigan Hospital
Providence Hospital and Medical Centers
Saint Mary’s Health Care - Grand Rapids, Mich.
Sparrow Hospital
Spectrum Health - Blodgett Campus
Spectrum Health-Butterworth Campus
St. Joseph Mercy Oakland
St. Mary’s of Michigan Medical Center
University of Michigan Health System – MMC
William Beaumont Hospital
Florida Stroke ActFlorida Stroke Act
Required EMS to take patients to Required EMS to take patients to primary stroke centers (JCAHO or primary stroke centers (JCAHO or state certified)state certified)
Resulted in significantly increased Resulted in significantly increased utilization of tPA at certified centersutilization of tPA at certified centers
Resulted in increased stroke volume Resulted in increased stroke volume at certified centersat certified centers
Important Advance – Stroke UnitsImportant Advance – Stroke Units
Outcomes improved (trends)Outcomes improved (trends)– Decreased disabilityDecreased disability– Reduced discharges to nursing homesReduced discharges to nursing homes– Reduced mortalityReduced mortality
Behavior changedBehavior changed– Increased use of tPAIncreased use of tPA
DisclaimerDisclaimer
Discussion from this point (other Discussion from this point (other than summary) is regarding than summary) is regarding experimental therapiesexperimental therapies
Some of these may be offered to Some of these may be offered to patients at centers in Michigan patients at centers in Michigan currentlycurrently
Some may notSome may not Some may turn out not to work…Some may turn out not to work…
Options other than tPAOptions other than tPA
Intra-arterial tPA (up Intra-arterial tPA (up to 6 hours)to 6 hours)
MERCI retrieval (up to MERCI retrieval (up to 6-8 hours) 6-8 hours)
Either could be Either could be considered in selected considered in selected cases when systemic cases when systemic tPA contra-indicated tPA contra-indicated or outside 3 hr windowor outside 3 hr window
Severity requirementSeverity requirementSource: Imaging Economics, November 2005
Recent Negative ResearchRecent Negative Research
NXY-059 (SAINT II)NXY-059 (SAINT II)– Neuro-protective agentNeuro-protective agent– Primary outcome not reachedPrimary outcome not reached
NovoSevenNovoSeven– Recombinant Factor VIIaRecombinant Factor VIIa– Hemostatic agent (ICH)Hemostatic agent (ICH)– Primary Outcome Not ReachedPrimary Outcome Not Reached– No longer seeking FDA approvalNo longer seeking FDA approval
Ongoing Acute Stroke Research at Ongoing Acute Stroke Research at UMHSUMHS
Multi-center Multi-center – CLEARCLEAR– TNKTNK– INSTINCTINSTINCT– NETTNETT
TNK / CLEARTNK / CLEAR
Studying alternate thrombolytic Studying alternate thrombolytic regimens to tPAregimens to tPA
Similar inclusionSimilar inclusion Similar outcome measuresSimilar outcome measures Proposed as potentially safer agentsProposed as potentially safer agents
INSTINCTINSTINCT
Multi-center trialMulti-center trial Targeted educational interventionTargeted educational intervention Involves 24 hospitals in MichiganInvolves 24 hospitals in Michigan Primary endpoint is appropriate use Primary endpoint is appropriate use
of tPAof tPA
NETTNETT
A multi-center network A multi-center network to engage in acute to engage in acute treatment trials in treatment trials in Neurologic Neurologic EmergenciesEmergencies
System of hubs and System of hubs and spokesspokes
U of M is clinical U of M is clinical coordinating centercoordinating center
Henry Ford and Wayne Henry Ford and Wayne State are hubsState are hubs
What is being studied What is being studied elsewhereelsewhere
Encouraging pilot / safety studiesEncouraging pilot / safety studies Highlighting therapies which may Highlighting therapies which may
have impact on acute care in futurehave impact on acute care in future
IMS-2IMS-2
2/3 of standard dose tPA given (0.6 2/3 of standard dose tPA given (0.6 mg/kg)mg/kg)
Cerebral angiogram Cerebral angiogram Additional bolus and infusion at Additional bolus and infusion at
embolism siteembolism site
Therapeutic hypothermiaTherapeutic hypothermia
Recommended therapy for comatose Recommended therapy for comatose survivors of out of hospital cardiac arrestsurvivors of out of hospital cardiac arrest
Feasibility study done in stroke – further Feasibility study done in stroke – further work ongoingwork ongoing
Prehospital MagnesiumPrehospital Magnesium
Novel system in LA county Novel system in LA county IV magnesium sulfate given to patients IV magnesium sulfate given to patients
identified in the field with severe acute identified in the field with severe acute ischemic strokeischemic stroke
www.fastmag.infowww.fastmag.info
Summary – take home pointsSummary – take home points
Time to treatment is keyTime to treatment is key Treat fever / hyperglycemiaTreat fever / hyperglycemia Permissive HTN in acute ischemic Permissive HTN in acute ischemic
strokestroke There are options beyond 3 hoursThere are options beyond 3 hours A great deal of exciting research is A great deal of exciting research is
going on in Michigan and around the going on in Michigan and around the worldworld
NeurologyLewis B. Morgenstern, MD Director
Devin L. Brown MD, MSMichael M. Wang MD PhD Kate Maddox, RNDarin Zahuranec, MDJennifer Majersik, MDWilliam Meurer, MD
NeurosurgeryJulian T. Hoff, MDB. Gregory Thompson, MD
Emergency MedicineWilliam G. Barsan, MDPhillip A. Scott, MDRobert Silbergleit, MDShirley Frederiksen, MS, BSNAnnette Sandretto, MSNWilliam Meurer, MD
CardiologyKim A. Eagle, MD
EpidemiologyLynda D. Lisabeth PhDMary N. Haan, PhD
RadiologyEllen Hoeffner, MDDheeraj Gandhi, MDJoe Gemette, MD
The University of Michigan Comprehensive Stroke Program
Physical Medicine& RehabilitationLisa DiPonio, MD
University of Michigan Stroke University of Michigan Stroke ProgramProgram
Website – Website – www.med.umich.eduwww.med.umich.edu My email – My email – [email protected]@umich.edu Please feel free to contact me if you Please feel free to contact me if you
would like an educational program at would like an educational program at your site!your site!