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?